Legacy On 10th Avenue
Topeka, Shawnee County, Kansas · CCN 175113 · For-profit (LLC) · part of Advena Living Communities (6 facilities, chain average 1.3 stars)
CMS rates Legacy On 10th Avenue 1 of 5 overall as of August 2026. 60 certified beds, 53 residents a day on average. 52 citations on record from the current inspection cycles, 1 at immediate jeopardy; no fines on record.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★★☆☆ 3 of 5 |
| Quality measures | ★★☆☆☆ 2 of 5 |
| Quality: long-stay / short-stay | 2 / — of 5 |
Staffing
| Total nurse staffing | 3.00711 hours per resident per day |
|---|---|
| Registered nurses | 0.50856 hours per resident per day |
| Weekend total | 2.70293 hours per resident per day |
| Nursing staff turnover | 65.4% (registered nurses 33.3%) |
| Administrators who left | 3 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-03-31 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-05-13 |
| 2026-03-31 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-05-13 |
| 2026-03-31 complaint survey |
Employ staff that are licensed, certified, or registered in accordance with state laws. Administration Deficiencies · tag F0839 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-05-13 |
| 2026-03-31 complaint survey |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · tag F0925 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-05-13 |
| 2026-03-31 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · tag F0947 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-05-13 |
| 2026-03-31 complaint survey |
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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-13 |
| 2026-03-31 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-13 |
| 2026-03-31 | 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. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-13 |
| 2026-03-31 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-13 |
| 2026-03-31 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · tag F0628 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-13 |
| 2026-03-31 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-13 |
| 2026-03-31 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-13 |
| 2026-03-31 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · tag F0582 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2026-05-13 |
| 2026-03-31 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2026-05-13 |
| 2025-07-07 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance 2025-07-02 |
| 2024-10-09 complaint survey |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Administration Deficiencies · tag F0838 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Honor the resident's right to manage his or her financial affairs. Resident Rights Deficiencies · tag F0567 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · tag F0585 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · tag F0680 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · tag F0925 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · tag F0553 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · tag F0849 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · tag F0576 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2024-11-20 |
| 2024-10-09 complaint survey |
Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2024-11-20 |
| 2024-06-18 complaint survey |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · tag F0623 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-19 |
| 2024-06-18 complaint survey |
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Resident Rights Deficiencies · tag F0625 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-19 |
| 2024-04-23 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-05-31 |
| 2023-10-25 complaint survey |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-06 |
| 2023-10-25 complaint survey |
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0691 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-06 |
| 2023-10-02 complaint survey |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · tag F0623 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-27 |
| 2023-04-18 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2023-06-30 |
| 2023-04-18 | 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. Nutrition and Dietary Deficiencies · tag F0801 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-05-22 |
| 2023-04-18 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-05-22 |
| 2023-04-18 | 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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-06-30 |
| 2023-04-18 | 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. Quality of Life and Care Deficiencies · tag F0700 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-05-22 |
| 2023-04-18 | 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. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-05-22 |
| 2023-04-18 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · tag F0925 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-05-22 |
| 2023-04-18 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-05-22 |
| 2023-04-18 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · tag F0582 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-05-22 |
| 2023-04-18 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-05-22 |
| 2023-04-18 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-05-22 |
| 2023-04-18 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · tag F0726 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-05-22 |
| 2023-04-18 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-06-30 |
| 2023-04-18 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-05-22 |
Fines and payment denials
No fines or payment denials on record since 2023.
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Cornerstone Employment Solutions Inc. Organization | adp of the snf | — | 2019-04-01 |
| New Paradigm Solutions Inc. Organization | adp of the snf | — | 2025-05-12 |
| Cghii Inc. Organization | direct ownership interest | — | 2019-04-01 |
| Cornerstone Group Holdings Inc. Organization | indirect ownership interest | — | 2019-04-01 |
| New Paradigm Solutions Inc. Organization | operational/managerial control | — | 2019-04-01 |
| Heston, Timothy Individual | adp of the snf | — | 2019-07-26 |
| Hopkins, Kimpton Individual | adp of the snf | — | 2025-01-06 |
| Novotny, Michelle Individual | indirect ownership interest | — | 2019-04-01 |
| Novotny, William Individual | indirect ownership interest | — | 2019-04-01 |
| Novotny, Michelle Individual | operational/managerial control | — | 2019-04-01 |
| Novotny, William Individual | operational/managerial control | — | 2019-04-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Legacy On 10th Avenue.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Shawnee County.