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.
Last standard health inspection on record
March 31, 2026
Showing 1 to 25 of 42 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.
The home gave a date the problem would be corrected (June 30, 2023).
No harm, with potential for more than minimal 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.
The home gave a date the problem would be corrected (May 22, 2023).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (May 22, 2023).
No harm, with potential for more than minimal harm
Develop and maintain an Emergency Preparedness Program (EP).
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Establish procedures for tracking staff and patients during an emergency.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Establish roles under a Waiver declared by secretary.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Provide emergency officials' contact information.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Provide primary/alternate means for communication.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Establish emergency prep training and testing.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Establish staff and initial training requirements.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Conduct testing and exercise requirements.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Install emergency lighting that can last at least 1 1/2 hours.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Provide properly protected cooking facilities.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
The home gave a date the problem would be corrected (June 15, 2023).
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.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
The home gave a date the problem would be corrected (May 31, 2024).
No harm, with potential for more than minimal 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.
The home gave a date the problem would be corrected (June 30, 2023).
No harm, with potential for more than minimal 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.
The home gave a date the problem would be corrected (May 22, 2023).
No harm, with potential for more than minimal 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.
The home gave a date the problem would be corrected (May 22, 2023).
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.
The home gave a date the problem would be corrected (May 22, 2023).
No harm, with potential for more than minimal harm
Use approved construction type or materials.
The home gave a date the problem would be corrected (June 15, 2023).
No harm, with potential for more than minimal harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
The home gave a date the problem would be corrected (June 15, 2023).
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.