Legacies Nursing And Rehabilitation - 4-Star Rehab Facility in Hemphill, TX | PlacetClinical Quality Indicators
Long-stay residents , lower is better
Antipsychotic medication use 13.06%Falls causing major injury 4.46%Pressure ulcers (high-risk) 4.03%Admissions Contacts
No admissions contacts on file yet.
CMS Star Ratings
⚠️ Last inspected: Jan 2025 (503 days ago)🔍 Health Inspection
5/5
★★★★★
📊 Quality Measures
1/5
★☆☆☆☆
Medicare
Source: CMS MDS Quality Measures. Updated quarterly.
State avg: 26 min · US avg: 41 min
Total Nurse / Resident / Day
3h 38m
State avg: 3h 24m · US avg: 3h 53m
1 min
State avg: 4 min · US avg: 4 min
52 per 100
State avg: 51 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
Weekend vs. Weekday RN
115%above avg
US avg: 64%
Total Nurse Weekend
2h 46m
Federal Penalties
No federal penalties in the past 3 years.
✅ No penalty records on file
Inspection Citations
Survey: January 15, 2025(3 citations)
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
Survey: December 20, 2023(24 citations)
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟡 Potential for HarmResident Rights DeficienciesComplaint
🟡 Potential for Harm
Survey: November 2, 2022(15 citations)
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
25.7 per 100
State avg: 25.9 · US avg: 23.9
17.6 per 100
State avg: 12.0 · US avg: 12.0
4.5 per 100
State avg: 3.3 · US avg: 3.3
4.0 per 100
State avg: 4.2 · US avg: 5.1
3.1 per 100
State avg: 1.5 · US avg: 1.6
92.7 per 100
State avg: 88.0 · US avg: 79.7
Rates shown per 100 patients · Green = better than average · Amber = average · Red = below average
VBP Performance Score
13/100
Incentive Payment
-1.88% penalty
Healthcare-Assoc. Infections
8.3 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Avg Length of Stay
50.6 days
Avg Payment / Stay
$19,610.25
Patient Complexity
1.94 × avg
Avg LOS 15-30 days is typical for short-term rehab · Patient complexity = HCC risk score (1.0 = national average; higher = sicker patient mix)
Resident Assessment and Care Planning Deficiencies
Complaint
🟡 Potential for HarmNutrition and Dietary DeficienciesComplaint
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟡 Potential for HarmResident Rights DeficienciesComplaint
🟡 Potential for HarmResident Assessment and Care Planning DeficienciesComplaint
🟡 Potential for HarmNutrition and Dietary DeficienciesComplaint
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟡 Potential for HarmResident Rights DeficienciesComplaint
🟡 Potential for HarmResident Assessment and Care Planning DeficienciesComplaint
🟡 Potential for HarmNutrition and Dietary DeficienciesComplaint
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
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