Public Record
Legacy on 10th Avenue
From CMS
Facility profile
- CMS overall rating
- 1 / 5
- Certified beds
- 60
- Avg. residents per day
- 55
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 120
- Inspections on file
- 13
- Last inspection
- 2026-03-31
*CMS
*CMS
*CMS
Citations
120 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0839Generalpotential for harm
Employ staff that are licensed, certified, or registered in accordance with state laws.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0584Generalpotential for harm
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.
- 0947Generalpotential for harm
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- 0582Generalno actual harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- 0628Generalpotential for harm
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0761Generalpotential for harm
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.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0553Generalpotential for harm
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0567Generalpotential for harm
Honor the resident's right to manage his or her financial affairs.
- 0576Generalno actual harm
Ensure residents have reasonable access to and privacy in their use of communication methods.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0584Generalpotential for harm
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.
- 0585Generalpotential for harm
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.
- 0680Generalpotential for harm
Ensure the activities program is directed by a qualified professional.
- 0679Generalpotential for harm
Provide activities to meet all resident's needs.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0758Generalpotential for harm
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.
- 0838Generalpotential for harm
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.
- 0849Generalpotential for harm
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.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0018Generalpotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0161Generalpotential for harm
Use approved construction type or materials.
- 0222Generalpotential for harm
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.
- 0293Generalpotential for harm
Have properly located and lighted "Exit" signs.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0354Generalpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0751Generalpotential for harm
Have restrictions on the use of flammable curtains.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0921Generalpotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0625Generalpotential for harm
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.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0691Generalpotential for harm
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0600Seriousimmediate jeopardy
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0610Seriousimmediate jeopardy
Respond appropriately to all alleged violations.
- 0699Generalpotential for harm
Provide care or services that was trauma informed and/or culturally competent.
- 0726Generalpotential for harm
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.
- 0761Generalpotential for harm
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.
- 0801Generalpotential for harm
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.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0354Generalpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0901Generalpotential for harm
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0018Generalpotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0026Generalpotential for harm
Establish roles under a Waiver declared by secretary.
- 0031Generalpotential for harm
Provide emergency officials' contact information.
- 0032Generalpotential for harm
Provide primary/alternate means for communication.
- 0036Generalpotential for harm
Establish emergency prep training and testing.
- 0037Generalpotential for harm
Establish staff and initial training requirements.
- 0039Generalpotential for harm
Conduct testing and exercise requirements.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0582Generalpotential for harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- 0584Generalpotential for harm
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.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0700Generalpotential for harm
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.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0161Generalpotential for harm
Use approved construction type or materials.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355Generalpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0362Generalpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0741Generalpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0761Generalpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0584Generalpotential for harm
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.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0325Generalpotential for harm
Have properly installed hallway dispensers for alcohol-based hand rub.
- 0293Generalpotential for harm
Have properly located and lighted "Exit" signs.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006Generalpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0009Generalpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0024Generalpotential for harm
Establish policies and procedures for volunteers.
- 0222Generalpotential for harm
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.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0924Generalpotential for harm
Put firmly secured handrails on each side of hallways.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection14 deficiencies
- View inspection reportInspection1 deficiency
- View inspection reportInspection34 deficiencies
- View inspection reportInspection34 deficiencies
- View inspection reportInspection2 deficiencies
- View inspection reportInspection1 deficiency
- View inspection reportInspection2 deficiencies
- View inspection reportInspection1 deficiency
- View inspection reportInspection3 deficiencies
- View inspection reportInspection35 deficiencies
Showing the 10 most recent inspections. 3 earlier inspections are also on record.
FAQ
Questions and answers
- What is Legacy on 10th Avenue?
- Legacy on 10th Avenue is a Medicare- and Medicaid-certified nursing home in Topeka, KS, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 175113.
- What is the CMS rating for Legacy on 10th Avenue?
- Legacy on 10th Avenue has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Legacy on 10th Avenue have?
- Legacy on 10th Avenue is certified for 60 beds. It serves an average of 55 residents per day.
- How many citations does Legacy on 10th Avenue have?
- Legacy on 10th Avenue has 120 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Legacy on 10th Avenue last inspected?
- Legacy on 10th Avenue was last inspected on March 31, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/175113-legacy-on-10th-avenue