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Inspection visit

Health inspection

LEGACY ON 10TH AVENUECMS #17511314 citations on this visit
14 citations recorded

Citations

14 citations recorded*CMS

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.

  • 0582GeneralS&S Cno actual harm

    F582 - The facility must—

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0584GeneralS&S Epotential for harm

    F584 - Safe Environment

    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.

  • 0628GeneralS&S Dpotential for harm

    F628 - Documentation

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0725GeneralS&S Fpotential for harm

    F725 - Nursing Services

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0732GeneralS&S Cno actual harm

    F732 - Nurse Staffing Information

    Post nurse staffing information every day.

  • 0755GeneralS&S Epotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0839GeneralS&S Fpotential for harm

    F839 - Staff qualifications

    Employ staff that are licensed, certified, or registered in accordance with state laws.

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0883GeneralS&S Dpotential for harm

    F883 - Influenza and pneumococcal immunizations

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0925GeneralS&S Fpotential for harm

    F925 - Maintain an effective pest control program so that the facility is free of

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  • 0947GeneralS&S Fpotential for harm

    F947 - Training Requirements

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

FAQ · About this visit

Common questions about this visit

What happened during the March 31, 2026 survey of LEGACY ON 10TH AVENUE?

This was a inspection survey of LEGACY ON 10TH AVENUE on March 31, 2026. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at LEGACY ON 10TH AVENUE on March 31, 2026?

Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.