Legacy Nursing and Rehabilitation Winnsboro

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

40.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 56 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 73.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 45 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 150 beds and averages 85.3 residents a day — about 57% occupied, or roughly 65 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.81 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.39 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.18 hrs/resident/day on weekends vs 4.07 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.35 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 13 most serious are shown; the remaining 15 are one tap away and print in full.

• Actual harm · H2024-05-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews, the facility failed to ensure a resident admitted with a urinary catheter received necessary treatment and services, consistent with professional standards to promote healing and prevent infections for 1 (#9) of 3 (#9, #40, and #231) sampled residents reviewed for urinary catheters. This failed practice resulted in actual harm for resident #9 on 04/16/2024 due to the facility failing to: 1. Ensure resident #9 was free of urinary tract infections as evidenced by resident #9 having a urinary tract infection on 04/16/2024 and again on 05/13/2024, and was treated with antibiotic therapy on both occasions for 5 days, beginning respectively on 04/17/2024 and 05/13/2024. 2. Assess the medical justification for the indication for use of a urinary catheter for resident #9 upon admission on [DATE]. 3. Ensure the facility documented the color, clarity and character of resident #9's urine as per resident #9's current care plan. Findings: Review of the facility's current…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-02-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to protect the residents' right to be free from physical and verbal abuse and psychosocial harm by staff for 1 (#7) of 4 (#1, #4, #5, and #7) sampled residents. The actual harm resulted for resident #7, who was cognitively impaired, on 02/13/2024 at approximately 1:12 p.m. when S3Certified Nursing Assistant (CNA) was witnessed being physically and verbally abusive to resident #7. S3CNA was witnessed by two Licensed Practical Nurses (LPNs) aggressively pull resident #7 up from her geri-chair and then popped her on the behind. S3CNA also was witnessed telling resident #7 to stop f______ pulling that sh__ down, I'm tired of the f______ sh__. Because this type of inappropriate, unwanted physical and verbal abuse would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in the resident's position would have experienced severe psychosocial harm-dehumanization, and humiliation- as a result of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that the resident received adequate supervision and assistance devices to prevent accidents for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents. The actual harm resulted for Resident #1 on 07/14/2023 when S4Certified Nursing Assistant (CNA) failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a transfer from the resident's wheelchair to bed. Resident #1 complained of pain and was sent to the local hospital. An x-ray of Resident #1's left hip showed comminuted displaced and angulated left hip and intertrochanteric fracture. Resident #1 was admitted to the hospital for management of her acute left hip fracture. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the current Hoyer Lift - Proper Use Policy and Procedure revealed, in part: Policy: 1. Residents who…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · E2025-07-09 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #74 On 07/07/2025 at 10:39 a.m. observation of Resident #74's room revealed the room was excessively dirty with debris and clutter and the room had a strong smell of urine. Further observation revealed a liquid that appeared to be urine all over bathroom floor. Further observation revealed that Resident #74's wheelchair had an excess of dirt and debris with both arm rests damaged. Interview with S2Director of Nursing (DON) on 07/09/2025 at 2:25 p.m. confirmed that staff had problems with keeping Resident #74's room clean and had to move all items out of room recently. S2DON confirmed that the wheelchair was damaged. Resident #76 On 07/07/2025 at 11:00 a.m. an observation of Resident #76's room revealed no linen/covers on her bed. Further observation revealed that her oxygen concentrator was dirty and there was a pair of shoes that were not the resident's lying on floor in her space. On 07/09/2025 at 2:25 p.m. an interview with S2DON confirmed linen/sheets should be available to all residents and that…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-07-09 · tag F0640 — pattern
  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record reviews and interviews, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed and transmitted timely for 4 (#34, #35, #55, and #59) of 4 sampled residents reviewed for resident assessment. Findings: Review of the records for Resident #34, #35, and #55 revealed each of these residents had a Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 05/27/2025. Further review of the record revealed these 3 MDS Assessments were not transmitted to state until 07/07/2025 for each of these residents. Review of the record for Resident #59 revealed an Annual MDS Assessment with an ARD date of 05/27/2025 was not transmitted to the state until 07/07/2025. An interview on 07/08/2025 at 2:50 p.m. with S13MDS Coordinator and S14MDS Coordinator confirmed the facility failed to complete and transmit MDS Assessments timely for Resident #34, #35, #55, and #59.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-07-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, policy review and interviews, the facility failed to store food and discard expired items in accordance with professional standards for food service safety. This deficient practice had the potential to effect the 63 residents that received meals prepared in the facility's kitchen. Findings: Review of the facility's Dietary Service policy and procedures dated 07/21/2016 revealed, in part, sanitary conditions are maintained in the storage, preparation, and distribution of food. On 07/07/2025 at 8:15 a.m. during an initial tour of the kitchen, observations revealed the following: -dust/grime build up on air vent near entrance to the kitchen; -grime/old food build up on base of large can opener; -large amount of old grease buildup in lower compartment of deep fryer and on the floor underneath the fryer; -2 commercial ovens have dark stains/old food buildup on inside of the oven doors and interior of both ovens; and -microwave had a large amount of old food splatters on inside top and sides of the microwave; -walk-in refrigerator had a large bin that had packages…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-07-09 · tag F0908 — failed to keep essential equipment working — pattern
  Keep all essential equipment working safely.
  What the surveyor found here — the official record, unedited, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews the facility failed to maintain electrical equipment in safe operating condition for 1 (#70) of 7 (#1, #5, #25, #70, #71, #74, #76) residents reviewed for environment. The facility failed to ensure that Resident #70's bed control was properly maintained and in safe working order. Findings: Review of the medical record for Resident #70 revealed an admission date of 06/17/2024 with diagnoses that included Alzheimer's disease, cerebrovascular disease, aphasia, dysphagia, repeated falls, and transient ischemic attack. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 6 which indicated Resident #70 had severe cognitive impairment. On 07/08/2025 at 9:28 a.m., an observation of Resident #70's room revealed a bed remote with exposed wires. On 07/09/2025 at 10:02 a.m., an observation with S15Maintenance Supervisor of Resident #70's bed control confirmed exposed wires.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-09 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to treat the resident with respect and dignity and care in a manner and in an environment that promotes or enhances his or her quality of life for 1 (#76) of 1 residents reviewed for dignity. The facility failed to ensure that Resident #76's privacy was maintained. Findings: Review of the record for Resident #76 revealed diagnoses of congestive heart failure, metabolic encephalopathy, and drug-induced subacute dyskinesia and aphasia. Review of Resident #76's Minimal Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment for daily decision making. Further review of the MDS revealed the resident was dependent on staff for Activities of Daily Living (ADL) and had limited range of motion on both sides other upper and lower extremities. Observations of Resident #76 on 07/07/2025 at 9:00 a.m., 11:30 a.m., 1:30 p.m., and 4:00 p.m. revealed the resident was lying in bed in the fetal position on her right side…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-09 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review and interview, the facility failed to complete a discharge summary for 1 (#89) of 1 closed records reviewed. Findings: Review of the facility's undated Discharge Transfer of a Resident Policy and Procedure revealed the following in part: Procedure- discharge: 6. Complete a discharge summary and post discharge plan of care form Review of Resident #89's record revealed an admission date of 03/31/2025 and discharge date of 04/30/2025. Further review of the record revealed no documentation of a discharge summary completed for Resident #89. An interview on 07/09/2025 at 8:45 a.m. with S2Director of Nursing (DON) confirmed Resident #89 was discharged from the facility on 04/30/2025. S2DON further confirmed there was no documentation of a discharge summary for Resident #89.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene for 2 (#11, #22) of 6 (#11, #14, #22, #56, #70, #74) residents reviewed for ADL care. Findings: Resident #22 Review of Resident #22's record revealed an admission date of 01/23/2025 with diagnoses that included cerebral infarction with hemiplegia and hemiparesis, chronic obstructive pulmonary disease, and congestive heart failure. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #22 had no cognitive impairment. Further review revealed Resident #22 required partial/moderate assistance with personal hygiene. Review of Resident #22's active care plan revealed she required assistance for all ADLs and needed assistance with hygiene and grooming tasks. On 07/07/2025 at 9:23 a.m., 07/08/2025…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#1) of 1 residents reviewed for position/mobility. The facility failed to ensure hand rolls and an elbow splint were provided for Resident #1's hand and arm contractures. Findings: Review of the record for Resident #1 revealed diagnoses of traumatic hemorrhage of cerebrum, hemiplegia, aphasia, and bilateral hand contractures. Review of the quarterly Minimal Data Set assessment dated [DATE] for Resident #1 revealed functional limitation in range of motion on both sides for upper extremity and impairment on both sides of lower extremity. Resident's cognitive skills for daily decision making were severely impaired. Observations on 07/07/2025 at 8:30 a.m. revealed Resident #1 had bilateral contractures with no splints in place. On 07/07/2025 at 1:30 p.m. and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to ensure the resident's environment remained free of accident hazards by failing to ensure bed rails were properly secured for 1 (#5) of 2 (#5, #11) residents reviewed for accident hazards. Findings: Review of the medical record for Resident #5 revealed an admission date of 09/23/2019 with diagnoses that included chronic obstructive pulmonary disease, bipolar disorder, dementia, and hyperlipidemia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 8 which indicated the resident had moderately impaired cognitive skills for daily decision making. Further review revealed Resident #5 was dependent with bed mobility. Review of the current plan of care addressed Resident #5's need for staff assistance with all activities of daily living. The resident required half side rails for turning and repositioning. Observations on 07/07/2025 at 9:15 a.m. and 07/08/2025 at 9:16 a.m.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #1 Review of the record for Resident #1 revealed an admit date of 05/01/2005 with diagnoses of hemiplegia, unspecified affecting unspecified side, and traumatic hemorrhage of cerebrum. Review of the current physician orders for Resident #1 revealed an order for oxygen therapy as follows: oxygen saturation level each shift, apply oxygen if saturation less than 92% at 2 liters per nasal cannula. Review of the care plan revealed a plan for at risk for respiratory infection related to Covid with interventions to administer oxygen as ordered. Observation of Resident #1 on 07/07/2025 at 8:23 a.m. revealed the oxygen concentrator flow set to three liters. Further observation revealed that the oxygen nasal cannula was lying on the floor. Further observation revealed that the concentrator was filthy with white debris splattered on it. Observation of Resident #1 on 07/07/2025 at 1:30 p.m. revealed the oxygen concentrator on and the flow set for three liters. Further observation revealed that the oxygen nasal…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$160,593 in federal fines across 2 penalties.

• $151,769 — penalty dated 2024-05-07
• $8,824 — penalty dated 2024-02-15

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to LEGACY NURSING & REHABILITATION — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 27 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in LA