Legacy on 10th Avenue
2015 SE 10th Avenue, Topeka, KS 66607 · All homes in Topeka
Legacy on 10th Avenue, a 60-bed for profit - limited liability company nursing facility in Topeka, KS, holds a 1-star CMS overall rating - below the 3.0-star national average, with nurse staffing below the national norm. 3 inspection findings reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 7852338918
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- 1 / 5
- Much below average · CMS overall · nat'l 3.0
- 3.03
- Well below average · nurse hrs/day · nat'l 3.89
- 45
- Inspection findings · 3 serious
- $104K
- Federal penalties (1)
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 175113
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 60
- Residents
- 52
- In Hospital
- No
- County
- Shawnee
- Last Inspection
- Oct 9, 2024
Staffing Data
How the 3.03 total nursing hours per resident-day are staffed:
- RN Hours
- 0.45 (nat'l avg: 0.68)
- LPN Hours
- 0.68
- CNA Hours
- 1.90
- Total Nursing Hours
- 3.03 (nat'l avg: 3.89)
- PT Hours
- 0.00
- Nursing Turnover
- 58.5%
- RN Turnover
- 50.0%
What the CMS Record Reveals About Legacy on 10th Avenue
Legacy on 10th Avenue operates 60 certified beds in Topeka, KS with approximately 52 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (2★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 45 deficiency records from recent surveys, of which 3 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $104K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.03 total nursing hours per resident day (national average 3.89), with RN coverage at 0.45 per resident day, the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, Legacy on 10th Avenue falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 58.5%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (45 most recent)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 2, 2025
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Nov 20, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Nov 20, 2024
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.
Category: Administration Deficiencies
Corrected: Nov 20, 2024
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.
Category: Administration Deficiencies
Corrected: Nov 20, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Nov 20, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Nov 20, 2024
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Nov 20, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 20, 2024
Ensure the activities program is directed by a qualified professional.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 20, 2024
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 20, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Nov 20, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Nov 20, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Nov 20, 2024
Ensure residents have reasonable access to and privacy in their use of communication methods.
Category: Resident Rights Deficiencies
Corrected: Nov 20, 2024
Honor the resident's right to manage his or her financial affairs.
Category: Resident Rights Deficiencies
Corrected: Nov 20, 2024
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Nov 20, 2024
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Category: Resident Rights Deficiencies
Corrected: Nov 20, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Jul 19, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Jul 19, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: May 31, 2024
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 6, 2023
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 6, 2023
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Oct 27, 2023
Provide care or services that was trauma informed and/or culturally competent.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 4, 2023
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 4, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 4, 2023
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: May 22, 2023
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: May 22, 2023
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.
Category: Nutrition and Dietary Deficiencies
Corrected: May 22, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 30, 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.
Category: Resident Rights Deficiencies
Corrected: Jun 30, 2023
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: May 22, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: May 22, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: May 22, 2023
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Jun 30, 2023
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.
Category: Nursing and Physician Services Deficiencies
Corrected: May 22, 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.
Category: Quality of Life and Care Deficiencies
Corrected: May 22, 2023
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: May 22, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 22, 2023
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: May 22, 2023
Put firmly secured handrails on each side of hallways.
Category: Environmental Deficiencies
Corrected: Nov 25, 2021
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Nov 25, 2021
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 25, 2021
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.
Category: Resident Rights Deficiencies
Corrected: Nov 25, 2021
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 19.5% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 2.7% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 7.0% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.4% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 12.3% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.4% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 35.0% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | N/A | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 7.2% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 1.5% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 99.5% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 42.1% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 98.1% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 13.7% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | N/A | No |
Penalty History 1 penalties totaling $104K
| Date | Type | Amount |
|---|---|---|
| Apr 18, 2023 | Fine | $104K |
| Apr 18, 2023 | Payment Denial | - |
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Understanding Nursing Home Data
Frequently Asked Questions
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When was Legacy on 10th Avenue last inspected?
What quality measures are tracked for Legacy on 10th Avenue?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
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