Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LEGACY ON 10TH AVENUE
TOPEKA, KS · 60 certified beds · Last Life Safety survey March 31, 2026
CMS Certification Number 175113 · first certified November 1976
Ownership
Operated by ADVENA LIVING COMMUNITIES · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within KS
47 citations — more than 94% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 19.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2027 — about 14 months from now. This facility’s last Life Safety survey was March 2026. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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7 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
9 of the 47 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
13 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 47 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
How that compares
Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 47 |
| Median facility in KS | 27 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 18, 2023 | 22 |
| October 9, 2024 | 17 |
| March 31, 2026 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-03-31 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2026-03-31 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 3 | 2026-03-31 |
| K-0324 | Provide properly protected cooking facilities. | 3 | 2026-03-31 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2026-03-31 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2026-03-31 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-10-09 |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | 2 | 2024-10-09 |
What the citations cover
- Smoke Deficiencies 16
- Emergency Preparedness Deficiencies 9
- Egress Deficiencies 7
- Miscellaneous Deficiencies 5
- Other 10
| Category | Citations |
|---|---|
| Smoke Deficiencies | 16 |
| Emergency Preparedness Deficiencies | 9 |
| Egress Deficiencies | 7 |
| Miscellaneous Deficiencies | 5 |
| Services Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Construction Deficiencies | 2 |
| Electrical Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 31, 2026 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 17, 2026) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (June 18, 2026) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 18, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 17, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 17, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 17, 2026) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 18, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 18, 2026) |
October 9, 2024 — 17 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 16, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 16, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 16, 2024) |
| K-0751 | Have restrictions on the use of flammable curtains. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (December 12, 2024) |
April 18, 2023 — 22 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (June 15, 2023) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (June 15, 2023) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (June 15, 2023) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (June 15, 2023) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (June 15, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (June 15, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (June 15, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 15, 2023) |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Deficient, Provider has date of correction (June 15, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.