Legacy On 10th Avenue
LEGACY ON 10TH AVENUE in TOPEKA, KS — inspection on March 31, 2026.
Found 14 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Federal health inspectors cited LEGACY ON 10TH AVENUE in TOPEKA, KS for a deficiency under regulatory tag F-F0582 during a standard health inspection conducted on 2026-03-31.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Scope/Severity Level C: pattern, no actual harm with potential for minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of LEGACY ON 10TH AVENUE.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-05-13.
limited to receiving treatment and supports for daily living safely.
observation and interviews, the facility failed to provide a clean, home-like environment for the
walk through of the East and West Halls, there was a distinct smell of urine.
While doing the walk through, up and down each hall revealed several urinals set on bedside tables and on the floors by the beds, some of the urinals did not have lids.
The hall foyer entry into the dining room had a distinct urine smell.An inspection was completed in the facility's laundry service room.
Laundry was stacked up, and four large grey tubs of laundry sat in the laundry room.
The laundry room was in the hall next to the kitchen foyer entry.The floor in the dining area was sticky and dirty, with multiple dried spills.On 03/31/26 at 12:05 PM, Licensed Nurse (LN) G stated she would have a Certified Nurse's Aides (CNAs) help her look for the source of the smell.
She stated she would check all the residents who were incontinent. LN G stated she would also get maintenance and housekeeping involved to find the source.On 03/23/26 at 12:25 PM, Administrative Nurse D started the staff should find the source of the odor.
She stated staff can give urinals with a lid, or ensure the urine was dumped more often.On 03/23/26 at 12:12 PM, Administrative Staff A stated her goal for the facility was that there were no foul odors in the building, and policies and procedures would be followed.
Administrative Staff A stated the facility did have a person in the facility who urinates in other places than the bathrooms.
She stated housekeeping keeps clean as soon as it was seen.The facility's Quality of Life-Home Environment policy undated documented residents were provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.
Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.
Clean, sanitary and orderly environment; Pleasant, neutral scents.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
175113 03/31/2026
Legacy on 10th Avenue 2015 SE 10th Avenue Topeka, KS 66607
Federal health inspectors cited LEGACY ON 10TH AVENUE in TOPEKA, KS for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2026-03-31.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of LEGACY ON 10TH AVENUE.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-05-13.
Federal health inspectors cited LEGACY ON 10TH AVENUE in TOPEKA, KS for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2026-03-31.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of LEGACY ON 10TH AVENUE.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-05-13.
Federal health inspectors cited LEGACY ON 10TH AVENUE in TOPEKA, KS for a deficiency under regulatory tag F-F0725 during a standard health inspection conducted on 2026-03-31.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of LEGACY ON 10TH AVENUE.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-05-13.
Federal health inspectors cited LEGACY ON 10TH AVENUE in TOPEKA, KS for a deficiency under regulatory tag F-F0732 during a standard health inspection conducted on 2026-03-31.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Post nurse staffing information every day.
Scope/Severity Level C: pattern, no actual harm with potential for minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of LEGACY ON 10TH AVENUE.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-05-13.
Federal health inspectors cited LEGACY ON 10TH AVENUE in TOPEKA, KS for a deficiency under regulatory tag F-F0755 during a standard health inspection conducted on 2026-03-31.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of LEGACY ON 10TH AVENUE.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-05-13.
Federal health inspectors cited LEGACY ON 10TH AVENUE in TOPEKA, KS for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2026-03-31.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: 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.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of LEGACY ON 10TH AVENUE.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-05-13.
serve food in accordance with professional standards.
on observation, record review, and interviews, the facility failed to follow sanitary dietary standards
tour on 03/24/26 at 09:10 AM, observation revealed the following:The dietary manager was not wearing a hair net, while in the kitchen area standing by the two-door refrigerator.The floors were sticky and dirty; tiles were missing off the floor next to the dishwasher.There were 17 trays with dried chili, cinnamon rolls and other foods on a tall silver cart, the trays were left from the previous day.
The dishwasher sink had standing water.
Dietary Staff BB stated the garbage disposal was backed up.The bowls and plates were not stored inverted.The steam table had dried food on the top, and dried food particles of dark brown substance that had run down the front of the table.
Underneath the steam table revealed grease and food residue.
Next to the steam table was a stainless-steel counter, the counter had dried food spilled down the side of the counter.
Under the counter was brown serving trays with dried white substance covering parts of the trays.Dietary Staff BB stated the ovens on the stove did not work, and staff were using the convection oven to bake their food.The kitchen door was propped open.In the two-door refrigerator in the kitchen prep area, observation revealed a bag of sliced turkey that was opened and undated.
The turkey was dripping juices on to the bottom shelves.In a single door white freezer, a box of chocolate chip cookie dough was opened and opened to air.In the double refrigerator in the serving area there was chocolate pudding unlabeled and undated, a bag of canned fruit, and small bowls of fruit that were unlabeled and undated.On 03/31/26 at 07:44 AM, a recheck of the kitchen revealed the ice scoop laid on top of the ice machine, the scoop was not in a container.
There was no thermometer in the milk cooler. On 03/23/26 at 09:25 AM, Dietary Staff BB stated all foods should be dated and labeled.
She stated the garbage disposal was backed up, and maintenance came in a fixed disposal.
Dietary Staff BB stated the steam table, and counters should be cleaned often and after each meal.
She stated dishes should be inverted.
She stated maintenance had been working on ordering parts and fixing the ovens in the kitchen.
Dietary Staff BB stated all dishes should be washed and put away and not left overnight. On 03/31/26 at 08:31 AM, Dietary Staff BB stated maintenance had plunged the garbage disposal and it was now in working order.
She stated she would get a thermometer in the milk cooler, and a container for the ice scoop.On 03/23/26 at 12:21 PM, Administrative Staff A was unaware the kitchen was not clean.
She stated her expectation was all staff follow policies and procedures.
She stated the kitchen had employee turnover in the last six months.
The facility's Food Receiving and Storage policy undated documented foods would be received and stored in a manner that complies with safe food handling practices.The facility's Sanitation policy undated documented the food service area shall be maintained in a clean and sanitary manner.
175113 03/31/2026
Legacy on 10th Avenue 2015 SE 10th Avenue Topeka, KS 66607
Findings included:- On 03/23/26 the facility report
since 11/30/25.
The facility verified LN H's lapsed nursing license through a search on Nursys (a national database for verification of nurse licensure) website: www.nursys.com and the Kansas State Board of Nursing (KSBN) website at www.kansas.gov/ksbn-verifications/. On 03/23/26 the surveyors conducted a search of the Nursys website and the KSBN and verified that LN H's nursing lapsed on 11/30/25. LN H continued working at the facility with a lapsed license up until 02/17/26.On 03/23/26 at 12:20 PM, Administrative Nurse D stated that human resources (HR) staff were responsible for verifying valid licenses and keeping track of the expiration dates.
Administrative Nurse D stated the facility has had some changeover in HR staff recently and it was found that the checking of the nursing licenses and nurse aide registry validations had not been kept up to date.On 03/23/26 at 10:45 AM, Administrative Staff A stated that she had found out after the turnover of three different HR staff in the past six months that nursing license verifications had not been completed for some time.
Administrative Staff A stated that Administrative Staff B was now the person that would be responsible for keeping track of licensures and nurse registry verification.The facility's Background Screening Investigations policy dated November 2023 documented for any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board is contacted to determine if any sanctions have been assessed against the applicant's license.
175113 03/31/2026
Legacy on 10th Avenue 2015 SE 10th Avenue Topeka, KS 66607
Federal health inspectors cited LEGACY ON 10TH AVENUE in TOPEKA, KS for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2026-03-31.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of LEGACY ON 10TH AVENUE.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-05-13.
Federal health inspectors cited LEGACY ON 10TH AVENUE in TOPEKA, KS for a deficiency under regulatory tag F-F0883 during a standard health inspection conducted on 2026-03-31.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Develop and implement policies and procedures for flu and pneumonia vaccinations.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of LEGACY ON 10TH AVENUE.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-05-13.
Monthly Report dated 02/24/26 documented recommendations with a high priority related to a hole in
The recommendations documented the hole in the wall was near the floor.On 03/24/26 at 11:32 AM, an observation of Resident (R) 5's room revealed a hole in the wall underneath his sink.On 03/24/26 at 12:05, Maintenance Supervisor U stated the hole remained in the wall. He stated he did not have time to fix the hole in the wall.
Maintenance Supervisor U stated the facility had done a mock survey, and the owners did a walk through, and had given him projects that had a deadline. He stated he had traps set up to catch mice and boxes outside to catch mice. He stated the mice had been less since the traps were set and he had fixed the outside of the building.On 03/31/26 at 12:00, Certified Nurses Aide (CNA) N stated when staff see mice or rodents in R5's room or R18's room the CNA would put that information into Facilities Work order System (TELS).
She stated the maintenance person gets this information and takes care of any situation.On 03/31/26 at 12:12, Licensed Nurse (LN) G stated she would call the maintenance supervisor to let them know right away there was a problem.On 03/31/26 at 12:25 PM, Administrative Nurse D stated the facility had a program to ensure all rooms and equipment were kept in good condition.
She stated rooms were checked weekly.On 3/31/26 at 02:10 PM, Administrative Staff A stated she expected any recommendations to be followed up on immediately.The facility's Pest Control policy undated documented the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.
Garbage and trash are not permitted to accumulate and are removed from the facility daily.
Maintenance services assist, when appropriate and necessary, in providing pest control services.
Federal health inspectors cited LEGACY ON 10TH AVENUE in TOPEKA, KS for a deficiency under regulatory tag F-F0947 during a standard health inspection conducted on 2026-03-31.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of LEGACY ON 10TH AVENUE.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-05-13.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TOPEKA, KS, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LEGACY ON 10TH AVENUE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.