Legacy on 10th Avenue
2015 Se 10th Avenue, Topeka, KS 66607
Legacy on 10th Avenue is a nursing home in Topeka, Kansas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (785) 233-8918
- Last standard health inspection
- March 31, 2026 (7 months ago)
- Certified beds
- 60
- Residents per day, on average
- 53.4
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Legacy on 10th Opco, LLC
- Chain
- Advena Living Communities
- Takes part in
- Medicare and Medicaid
More health citations than the Kansas average (66 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 1 of 5.
14 citations
Health inspection on August 4, 2026
CMS lists this as a complaint inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 11, 2026.
CMS has cited this home for F0812 2 times since 2026.
Citation F0925. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on September 11, 2026.
CMS has cited this home for F0925 4 times since 2023.
Citation F0569. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
CMS lists it as corrected on September 11, 2026.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on September 11, 2026.
CMS has cited this home for F0755 3 times since 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 11, 2026.
CMS has cited this home for F0880 4 times since 2023.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on September 11, 2026.
CMS has cited this home for F0550 2 times since 2023.
Citation F0557. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
CMS lists it as corrected on September 11, 2026.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on September 11, 2026.
Citation F0638. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assure that each resident’s assessment is updated at least once every 3 months.
CMS lists it as corrected on September 11, 2026.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on September 11, 2026.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 11, 2026.
CMS has cited this home for F0689 5 times since 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on September 11, 2026.
CMS has cited this home for F0690 2 times since 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on September 11, 2026.
Citation F0726. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS lists it as corrected on September 11, 2026.
CMS has cited this home for F0726 2 times since 2023.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
14 citations
Health inspection on March 31, 2026
CMS lists this as a standard inspection and a complaint inspection.
Citation F0725. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on May 13, 2026.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 13, 2026.
Citation F0839. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Employ staff that are licensed, certified, or registered in accordance with state laws.
CMS lists it as corrected on May 13, 2026.
Citation F0925. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on May 13, 2026.
Citation F0947. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on May 13, 2026.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 13, 2026.
CMS has cited this home for F0584 3 times since 2023.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 13, 2026.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 13, 2026.
CMS has cited this home for F0761 2 times since 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 13, 2026.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on May 13, 2026.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 13, 2026.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on May 13, 2026.
Citation F0582. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on May 13, 2026.
CMS has cited this home for F0582 2 times since 2023.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on May 13, 2026.
CMS has cited this home for F0732 2 times since 2024.
8 citations
Fire safety inspection on March 31, 2026
CMS lists this as a standard inspection.
Citation K0211. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on June 17, 2026.
CMS has cited this home for K0211 2 times since 2023.
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on June 18, 2026.
CMS has cited this home for K0222 2 times since 2024.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on June 18, 2026.
CMS has cited this home for K0291 2 times since 2023.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on June 17, 2026.
CMS has cited this home for K0345 2 times since 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 17, 2026.
CMS has cited this home for K0353 3 times since 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on June 18, 2026.
CMS has cited this home for K0712 3 times since 2023.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on June 17, 2026.
CMS has cited this home for K0324 3 times since 2023.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on June 18, 2026.
CMS has cited this home for K0511 3 times since 2023.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Ownership
CMS lists this home under a new chain.
CMS update of July 30, 2025
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
Staffing
Total nurse staffing reported to CMS went from 3.3 to 2.9 hours per resident per day.
1 citation
Health inspection on July 7, 2025
CMS lists this as a complaint inspection.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 2, 2025.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Fine
CMS changed the fine from November 1, 2022 from $9,750 to $9,928.
17 citations
Health inspection on October 9, 2024
CMS lists this as a standard inspection and a complaint inspection.
Citation F0838. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
CMS lists it as corrected on November 20, 2024.
Citation F0567. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to manage his or her financial affairs.
CMS lists it as corrected on November 20, 2024.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 20, 2024.
Citation F0585. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
CMS lists it as corrected on November 20, 2024.
Citation F0679. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on November 20, 2024.
Citation F0680. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure the activities program is directed by a qualified professional.
CMS lists it as corrected on November 20, 2024.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 20, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 20, 2024.
Citation F0925. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on November 20, 2024.
Citation F0553. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
CMS lists it as corrected on November 20, 2024.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on November 20, 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on November 20, 2024.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on November 20, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 20, 2024.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 20, 2024.
Citation F0576. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Ensure residents have reasonable access to and privacy in their use of communication methods.
CMS lists it as corrected on November 20, 2024.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on November 20, 2024.
17 citations
Fire safety inspection on October 9, 2024
CMS lists this as a standard inspection.
Citation E0018. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish procedures for tracking staff and patients during an emergency.
CMS lists it as corrected on December 12, 2024.
CMS has cited this home for E0018 2 times since 2023.
Citation K0161. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on December 12, 2024.
CMS has cited this home for K0161 2 times since 2023.
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on December 12, 2024.
Citation K0293. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on December 12, 2024.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on December 12, 2024.
CMS has cited this home for K0321 2 times since 2023.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on December 12, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 16, 2024.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on December 12, 2024.
CMS has cited this home for K0354 2 times since 2023.
Citation K0363. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on December 16, 2024.
CMS has cited this home for K0363 2 times since 2023.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on December 12, 2024.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on December 12, 2024.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on December 12, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on December 16, 2024.
Citation K0751. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have restrictions on the use of flammable curtains.
CMS lists it as corrected on December 12, 2024.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on December 12, 2024.
Citation K0920. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on December 12, 2024.
Citation K0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that testing and maintenance of electrical equipment is performed.
CMS lists it as corrected on December 12, 2024.
CMS update of August 29, 2024
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of July 31, 2024
Staffing
Total nurse staffing reported to CMS went from 2.7 to 2.1 hours per resident per day.
2 citations
Health inspection on June 18, 2024
CMS lists this as a complaint inspection.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on July 19, 2024.
CMS has cited this home for F0623 2 times since 2023.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 19, 2024.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
1 citation
Health inspection on April 23, 2024
CMS lists this as a complaint inspection.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 31, 2024.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Fine
CMS changed the fine from March 2, 2021 from $19,170 to $12,461.
Fine
CMS changed the fine from April 28, 2021 from $19,170 to $12,461.
Fine
CMS changed the fine from November 1, 2022 from $15,000 to $9,750.
Fine
CMS changed the fine from April 18, 2023 from $97,234 to $103,737.
2 citations
Health inspection on October 25, 2023
CMS lists this as a complaint inspection.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on December 6, 2023.
Citation F0691. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
CMS lists it as corrected on December 6, 2023.
1 citation
Health inspection on October 2, 2023
CMS lists this as a complaint inspection.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on October 27, 2023.
14 citations
Health inspection on April 18, 2023
CMS lists this as a standard inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
25 of 296 Kansas homes (8%) got a citation at the immediate jeopardy level in 2023.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 30, 2023.
Citation F0801. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
CMS lists it as corrected on May 22, 2023.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 22, 2023.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on June 30, 2023.
Citation F0700. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 22, 2023.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 22, 2023.
Citation F0925. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on May 22, 2023.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on May 22, 2023.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on May 22, 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on May 22, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on May 22, 2023.
Citation F0726. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS lists it as corrected on May 22, 2023.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on June 30, 2023.
Citation F0804. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on May 22, 2023.
22 citations
Fire safety inspection on April 18, 2023
CMS lists this as a standard inspection.
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on June 15, 2023.
Citation E0018. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish procedures for tracking staff and patients during an emergency.
CMS lists it as corrected on June 15, 2023.
Citation E0026. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish roles under a Waiver declared by secretary.
CMS lists it as corrected on June 15, 2023.
Citation E0031. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide emergency officials' contact information.
CMS lists it as corrected on June 15, 2023.
Citation E0032. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide primary/alternate means for communication.
CMS lists it as corrected on June 15, 2023.
Citation E0036. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish emergency prep training and testing.
CMS lists it as corrected on June 15, 2023.
Citation E0037. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish staff and initial training requirements.
CMS lists it as corrected on June 15, 2023.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on June 15, 2023.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on June 15, 2023.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on June 15, 2023.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on June 15, 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 15, 2023.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on June 15, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on June 15, 2023.
Citation K0901. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
CMS lists it as corrected on June 15, 2023.
Citation K0161. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on June 15, 2023.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on June 15, 2023.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on June 15, 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on June 15, 2023.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on June 15, 2023.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on June 15, 2023.
Citation K0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on June 15, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CGHII INCDirect ownership interest · not applicable · since 04/01/2019
- CORNERSTONE GROUP HOLDINGS INCIndirect ownership interest · not applicable · since 04/01/2019
- NOVOTNY, MICHELLEIndirect ownership interest · not applicable · since 04/01/2019
- NOVOTNY, WILLIAMIndirect ownership interest · not applicable · since 04/01/2019
- NEW PARADIGM SOLUTIONS INCOperational/managerial control · not applicable · since 04/01/2019
- NOVOTNY, MICHELLEOperational/managerial control · not applicable · since 04/01/2019
- NOVOTNY, WILLIAMOperational/managerial control · not applicable · since 04/01/2019
Questions
When was Legacy on 10th Avenue last inspected?
CMS lists March 31, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Legacy on 10th Avenue have?
CMS lists 66 health citations since April 18, 2023. CMS also calls these deficiencies.
Has Legacy on 10th Avenue been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Legacy on 10th Avenue?
Its CMS overall star rating is 1 of 5.
Is Legacy on 10th Avenue a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.