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Legacy On 10th Avenue

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About Legacy On 10th Avenue

General Information

Legal Business NameLegal Business Name Not Available
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareNovember 30, 1976 (40 years)
Capacity76
Residents72
Percent Occupied95%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Legacy On 10th Avenue

Legacy On 10th Avenue
was reviewed by Medicare to have a rating of 1 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Kansas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

September 9, 2015 - 15 months ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 9 days
---Fine$12,950 fine
KSomeImmediate JeopardyComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
FManyPotential for HarmComplaint+InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
ESomePotential for HarmComplaint+InspectionMake sure that a working call system is available in each resident's room or bathroom and bathing area.
ESomePotential for HarmComplaint+InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmComplaint+Inspection1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews.
ESomePotential for HarmComplaint+InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmComplaint+InspectionProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
CManyPotential for Minimal HarmComplaint+InspectionSend unopened mail from residents and promptly deliver unopened mail to residents.
CManyPotential for Minimal HarmComplaint+InspectionEmploy or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
DFewPotential for HarmComplaint+InspectionMake sure that doctors visit residents regularly, as required.
DFewPotential for HarmComplaint+InspectionAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
DFewPotential for HarmComplaint+InspectionProvide or obtain dental services for each resident.
DFewPotential for HarmComplaint+InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
DFewPotential for HarmComplaint+InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmComplaint+Inspection1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
DFewPotential for HarmComplaint+InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
DFewPotential for HarmComplaint+InspectionEnsure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.
DFewPotential for HarmComplaint+InspectionDevelop policies and procedures for influenza and pneumococcal immunizations.
DFewPotential for HarmComplaint+InspectionGive residents a notice of rights, rules, services and charges.
DFewPotential for HarmComplaint+InspectionHave enough nurses to care for every resident in a way that maximizes the resident's well being.

June 23, 2015 - 18 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.

May 18, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionAn approved installation, maintenance and testing program for fire alarm systems.
FManyPotential for HarmFire Safety InspectionExits that are accessible at all times.
FManyPotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
FManyPotential for HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
ESomePotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
ESomePotential for HarmFire Safety InspectionEmergency lighting that can last at least 1 1/2 hours.
ESomePotential for HarmFire Safety InspectionApproved construction type or materials.
DFewPotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
DFewPotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
DFewPotential for HarmFire Safety InspectionProper medical gas storage and administration areas.

April 30, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.

March 18, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
CManyPotential for Minimal HarmComplaintDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

May 21, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 54 days
FManyPotential for HarmComplaint+InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmComplaint+InspectionHave enough nurses to care for every resident in a way that maximizes the resident's well being.
FManyPotential for HarmComplaint+InspectionHave a program that investigates, controls and keeps infection from spreading.
FManyPotential for HarmComplaint+InspectionKeep all essential equipment working safely.
FManyPotential for HarmComplaint+InspectionMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
FManyPotential for HarmComplaint+InspectionSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
GFewActual HarmComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
GFewActual HarmComplaint+InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
ESomePotential for HarmComplaint+InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
ESomePotential for HarmComplaint+InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
ESomePotential for HarmComplaint+InspectionProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
ESomePotential for HarmComplaint+InspectionUse a registered nurse at least 8 hours a day, 7 days a week.
ESomePotential for HarmComplaint+InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
ESomePotential for HarmComplaint+InspectionGive residents a notice of rights, rules, services and charges.
ESomePotential for HarmComplaint+InspectionProvide proof that residents' personal money that is deposited with the nursing home is secure.
ESomePotential for HarmComplaint+InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
ESomePotential for HarmComplaint+InspectionProvide housekeeping and maintenance services.
ESomePotential for HarmComplaint+InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
CManyPotential for Minimal HarmHealth InspectionPost nurse staffing information/data on a daily basis.
CManyPotential for Minimal HarmComplaint+InspectionAllow residents to easily view the results of the nursing home's most recent inspection.
DFewPotential for HarmHealth InspectionLet residents refuse treatment, refuse to take part in an experiment, or formulate advance directives.
DFewPotential for HarmComplaint+InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
DFewPotential for HarmComplaint+InspectionAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
DFewPotential for HarmHealth InspectionEnsure services provided by the nursing facility meet professional standards of quality.
DFewPotential for HarmComplaint+InspectionMake sure that a working call system is available in each resident's room or bathroom and bathing area.
DFewPotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
DFewPotential for HarmComplaint+InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
DFewPotential for HarmComplaint+InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmComplaint+InspectionGive or get specialized rehabilitative services per the patient's assessment or plan of care.
DFewPotential for HarmComplaint+InspectionEnsure residents maintain acceptable nutritional status.
DFewPotential for HarmComplaint+InspectionUpon the death of a resident, convey the residentís personal funds and an accounting of those funds to the appropriate party.
DFewPotential for HarmComplaint+InspectionEnsure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.
DFewPotential for HarmComplaint+InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmComplaint+InspectionTry to resolve each resident's complaints quickly.
DFewPotential for HarmComplaint+InspectionReview or revise the resident's care plan after any major change in physical or mental health.
DFewPotential for HarmComplaint+InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaint+InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
DFewPotential for HarmComplaint+InspectionMake sure that residents receive treatments/services to maintain or improve their ability to care for themselves.
DFewPotential for HarmComplaint+InspectionAllow residents the right to participate in the planning or revision of care and treatment.

January 30, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionPosted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
FManyPotential for HarmFire Safety InspectionProperly protected cooking facilities.
FManyPotential for HarmFire Safety InspectionRestrictions on the use of highly flammable decorations.
FManyPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
FManyPotential for HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
FManyPotential for HarmFire Safety InspectionEmergency lighting that can last at least 1 1/2 hours.
FManyPotential for HarmFire Safety InspectionProperly located and lighted "Exit" signs.
DFewPotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
DFewPotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.

December 20, 2013 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.

July 9, 2013 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 71 days
---Fine$4,408 fine
---Fine$7,792 fine

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Legacy On 10th Avenue require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 30min
2hr
ReportedExpected
CNA
35min
35min
ReportedExpected
LPN
30min
55min
ReportedExpected
RN
3hr 40min
3hr 35min
ReportedExpected
Total Nursing

This facility also provides approximately 1min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

86.4%
79.2%
79.2%
96.5%
Q1 2015Q2 2015Q3 2015KS
Assessed and Appropriately Given the Seasonal Influenza Vaccine
59.1%
90.0%
97.1%
93.5%
Q1 2015Q2 2015Q3 2015KS
Assessed and Appropriately Given the Pneumococcal Vaccine
34.1%
23.3%
15.6%
40.2%
Q1 2015Q2 2015Q3 2015KS
Low Risk Residents Who Lose Control of Their Bowel or Bladder
34.1%
23.3%
24.4%
19.9%
Q1 2015Q2 2015Q3 2015KS
Received an Antipsychotic Medication
-
-
-
17.5%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
Need for Help with ADLs has Increased
5.3%
4.2%
7.5%
11.0%
Q1 2015Q2 2015Q3 2015KS
Self Report Moderate to Severe Pain
4.8%
3.0%
5.9%
7.4%
Q1 2015Q2 2015Q3 2015KS
Lose Too Much Weight
-
-
-
5.3%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
High Risk Residents With Pressure Ulcers
1.7%
3.1%
4.8%
7.1%
Q1 2015Q2 2015Q3 2015KS
Have Depressive Symptoms
0.0%
0.0%
6.0%
6.6%
Q1 2015Q2 2015Q3 2015KS
With a Urinary Tract Infection
10.6%
8.6%
8.8%
5.0%
Q1 2015Q2 2015Q3 2015KS
Experiencing One or More Falls with Major Injury
0.0%
2.0%
2.1%
3.0%
Q1 2015Q2 2015Q3 2015KS
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.3%
Q1 2015Q2 2015Q3 2015KS
Were Physically Restrained

Quality Measures for Short Stay Residents

30.4%
54.2%
-
77.6%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
Assessed and Appropriately Given the Pneumococcal Vaccine
-
34.8%
34.8%
77.9%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
-
-
-
21.2%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
Self Report Moderate to Severe Pain
-
-
-
2.7%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
Newly Received an Antipsychotic Medication
0.0%
0.0%
-
1.5%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
With Pressure Ulcers That Are New or Worsened