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Legacy On 10th Avenue

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About Legacy On 10th Avenue

General Information

Legal Business NameLegacy On 10th Opco, LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareNovember 30, 1976 (41 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

November 2, 2016 - 10 months ago

 Residents AffectedSeveritySource/TypeDescription
GFewActual HarmComplaintProtect each resident from all abuse, physical punishment, and involuntary separation from others.
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.

October 19, 2016 - 10 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .

December 31, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaintHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmComplaintEnsure 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 HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .

September 9, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$12,950 fine
---Payment DenialPayment denial for 9 days
KSomeImmediate JeopardyComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
FManyPotential for HarmHealth InspectionSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
FManyPotential for HarmComplaint+InspectionStore, cook, and serve food in a safe and clean way.
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.
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+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.
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.
CManyPotential for Minimal HarmComplaint+InspectionSend unopened mail from residents and promptly deliver unopened mail to residents.
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+InspectionMake sure that doctors visit residents regularly, as required.
DFewPotential for HarmComplaint+InspectionProvide or obtain dental services for each resident.
DFewPotential for HarmComplaint+InspectionHave enough nurses to care for every resident in a way that maximizes the resident's 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+InspectionGive residents a notice of rights, rules, services and charges.
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+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+InspectionDevelop policies and procedures for influenza and pneumococcal immunizations.

June 23, 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.
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.

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

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

79.2%
71.2%
71.2%
71.2%
95.4%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
92.3%
81.2%
83.3%
100.0%
92.8%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
39.1%
55.6%
47.9%
52.0%
39.7%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of low risk long-stay residents who lose control of their bowels or bladder
25.4%
30.0%
25.4%
22.0%
24.3%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents who received an antianxiety or hypnotic medication
-
-
20.5%
31.9%
19.3%
Q4 2015Q1 2016Q2 2016Q3 2016KS
* The data for this facility for some quarters is unavailable.
Percentage of long-stay residents whose ability to move independently worsened
17.1%
10.8%
19.5%
18.4%
20.2%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents who received an antipsychotic medication
-
41.7%
24.6%
14.0%
16.7%
Q4 2015Q1 2016Q2 2016Q3 2016KS
* The data for this facility for some quarters is unavailable.
Percentage of long-stay residents whose need for help with daily activities has increased
12.9%
17.1%
22.1%
11.3%
10.4%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents who self-report moderate to severe pain
7.9%
16.1%
4.6%
1.6%
7.5%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents who lose too much weight
0.0%
0.0%
8.6%
10.3%
5.2%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of high risk long-stay residents with pressure ulcers
5.6%
1.9%
0.0%
1.9%
6.4%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents who have depressive symptoms
4.8%
6.6%
3.1%
4.7%
6.0%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents with a urinary tract infection
9.2%
4.7%
1.5%
3.1%
4.8%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents experiencing one or more falls with major injury
2.1%
1.8%
1.4%
0.0%
2.6%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
0.0%
0.0%
0.0%
0.2%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

33.3%
-
-
-
76.2%
Q4 2015Q1 2016Q2 2016Q3 2016KS
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
34.8%
-
-
-
74.2%
Q4 2015Q1 2016Q2 2016Q3 2016KS
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
-
-
-
-
69.5%
Q4 2015Q1 2016Q2 2016Q3 2016KS
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who made improvements in function
-
-
-
-
20.9%
Q4 2015Q1 2016Q2 2016Q3 2016KS
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who self-report moderate to severe pain
-
-
-
-
2.7%
Q4 2015Q1 2016Q2 2016Q3 2016KS
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who newly received an antipsychotic medication
0.0%
-
-
-
1.9%
Q4 2015Q1 2016Q2 2016Q3 2016KS
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents with pressure ulcers that are new or worsened