All citations for Legacy on 10th Avenue

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Legacy on 10th Avenue

Last standard health inspection on record

March 31, 2026

Showing 1 to 25 of 99 citations

Immediate jeopardy to resident health or safety
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Isolated (one or a few residents). CMS level J.
Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 30, 2023).
No harm, with potential for more than minimal harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Widespread (many residents). CMS level F.
Health citation F-0725, Nursing and Physician Services Deficiencies. Inspection of March 31, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 13, 2026).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Widespread (many residents). CMS level F.
Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of March 31, 2026. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (May 13, 2026).
No harm, with potential for more than minimal harm
Employ staff that are licensed, certified, or registered in accordance with state laws.
Widespread (many residents). CMS level F.
Health citation F-0839, Administration Deficiencies. Inspection of March 31, 2026. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (May 13, 2026).
No harm, with potential for more than minimal harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Widespread (many residents). CMS level F.
Health citation F-0925, Environmental Deficiencies. Inspection of March 31, 2026. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (May 13, 2026).
No harm, with potential for more than minimal harm
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Widespread (many residents). CMS level F.
Health citation F-0947, Nursing and Physician Services Deficiencies. Inspection of March 31, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 13, 2026).
No harm, with potential for more than minimal harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Widespread (many residents). CMS level F.
Fire safety citation K-0211, Egress Deficiencies. Inspection of March 31, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 17, 2026).
No harm, with potential for more than minimal 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.
Widespread (many residents). CMS level F.
Fire safety citation K-0222, Egress Deficiencies. Inspection of March 31, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 18, 2026).
No harm, with potential for more than minimal harm
Install emergency lighting that can last at least 1 1/2 hours.
Widespread (many residents). CMS level F.
Fire safety citation K-0291, Egress Deficiencies. Inspection of March 31, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 18, 2026).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0345, Smoke Deficiencies. Inspection of March 31, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 17, 2026).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of March 31, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 17, 2026).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
Widespread (many residents). CMS level F.
Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of March 31, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 18, 2026).
No harm, with potential for more than minimal 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.
Widespread (many residents). CMS level F.
Health citation F-0838, Administration Deficiencies. Inspection of October 9, 2024. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (November 20, 2024).
No harm, with potential for more than minimal harm
Establish procedures for tracking staff and patients during an emergency.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0018, Emergency Preparedness Deficiencies. Inspection of October 9, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (December 12, 2024).
No harm, with potential for more than minimal harm
Use approved construction type or materials.
Widespread (many residents). CMS level F.
Fire safety citation K-0161, Construction Deficiencies. Inspection of October 9, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (December 12, 2024).
No harm, with potential for more than minimal 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.
Widespread (many residents). CMS level F.
Fire safety citation K-0222, Egress Deficiencies. Inspection of October 9, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (December 12, 2024).
No harm, with potential for more than minimal harm
Have properly located and lighted "Exit" signs.
Widespread (many residents). CMS level F.
Fire safety citation K-0293, Egress Deficiencies. Inspection of October 9, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (December 12, 2024).
No harm, with potential for more than minimal harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Widespread (many residents). CMS level F.
Fire safety citation K-0321, Smoke Deficiencies. Inspection of October 9, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (December 12, 2024).
No harm, with potential for more than minimal harm
Provide properly protected cooking facilities.
Widespread (many residents). CMS level F.
Fire safety citation K-0324, Smoke Deficiencies. Inspection of October 9, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (December 12, 2024).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of October 9, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (December 16, 2024).
No harm, with potential for more than minimal harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Widespread (many residents). CMS level F.
Fire safety citation K-0354, Smoke Deficiencies. Inspection of October 9, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (December 12, 2024).
No harm, with potential for more than minimal harm
Install corridor and hallway doors that block smoke.
Widespread (many residents). CMS level F.
Fire safety citation K-0363, Smoke Deficiencies. Inspection of October 9, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (December 16, 2024).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Widespread (many residents). CMS level F.
Fire safety citation K-0372, Smoke Deficiencies. Inspection of October 9, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (December 12, 2024).
No harm, with potential for more than minimal harm
Have properly installed electrical wiring and gas equipment.
Widespread (many residents). CMS level F.
Fire safety citation K-0511, Services Deficiencies. Inspection of October 9, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (December 12, 2024).
No harm, with potential for more than minimal harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Widespread (many residents). CMS level F.
Fire safety citation K-0521, Services Deficiencies. Inspection of October 9, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (December 12, 2024).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.