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 22 of 22 citations

  1. No harm, with potential for more than minimal harm

    Develop and maintain an Emergency Preparedness Program (EP).

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0004, Emergency Preparedness Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  2. 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 April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  3. No harm, with potential for more than minimal harm

    Establish roles under a Waiver declared by secretary.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0026, Emergency Preparedness Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  4. No harm, with potential for more than minimal harm

    Provide emergency officials' contact information.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0031, Emergency Preparedness Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  5. No harm, with potential for more than minimal harm

    Provide primary/alternate means for communication.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0032, Emergency Preparedness Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  6. No harm, with potential for more than minimal harm

    Establish emergency prep training and testing.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0036, Emergency Preparedness Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  7. No harm, with potential for more than minimal harm

    Establish staff and initial training requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0037, Emergency Preparedness Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  8. No harm, with potential for more than minimal harm

    Conduct testing and exercise requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0039, Emergency Preparedness Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  9. 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 April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  10. 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 April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  11. 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 April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  12. 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 April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  13. 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 April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  14. 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 April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  15. No harm, with potential for more than minimal harm

    Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0901, Electrical Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  16. No harm, with potential for more than minimal harm

    Use approved construction type or materials.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0161, Construction Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  17. No harm, with potential for more than minimal harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0211, Egress Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  18. 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.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  19. No harm, with potential for more than minimal harm

    Install corridor and hallway doors that block smoke.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  20. No harm, with potential for more than minimal harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0374, Smoke Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  21. No harm, with potential for more than minimal harm

    Have properly installed electrical wiring and gas equipment.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0511, Services Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 15, 2023).

  22. No harm, with potential for more than minimal harm

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of April 18, 2023. Found during a standard inspection.

    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 October 1, 2026. Inspection results describe the home at the time of each inspection.