Cycle 1
Health 2025-01-15 · Fire 2025-01-15
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Hemphill, TX
Legacies Nursing And Rehabilitation
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
355 Fm 83 W, Hemphill, TX
(409) 787-5300
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
85
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Chambers County Public Hospital District No. 1
Operator or chain grouping
Approved since
2013-10-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.20
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.63
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
0.99
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.22
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,226
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.38% · Performance 21.86% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.57% · Performance 8.30% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.35
Performance 50.00% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2
Baseline 3.18 hours · Performance 3.65 hours · Measure score 2 · Achievement 2 · Improvement 1.30
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.83% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 7.69% · Lower 95% interval 6.62% |
| Discharge to community | 42.15% |
50.57%
8.4 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 36.51% · Lower 95% interval 32.54% |
| Medicare spending per beneficiary | 1.66 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 98.94% |
95.27%
3.7 pts better
|
Numerator 93 · Denominator 94 |
| Falls with major injury | 1.06% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 94 |
| Discharge self-care score | 67.19% |
53.69%
13.5 pts better
|
Numerator 43 · Denominator 64 |
| Discharge mobility score | 39.06% |
50.94%
11.9 pts worse
|
Numerator 25 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 1.06% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 94 · Adjusted rate 1.05% |
| Healthcare-associated infections requiring hospitalization | 8.3% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 10.45% · Lower 95% interval 5.13% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 102 |
| Staff flu vaccination coverage | 43.52% |
42%
1.5 pts better
|
Numerator 47 · Denominator 108 |
| Discharge function score | 60.94% |
56.45%
4.5 pts better
|
Numerator 39 · Denominator 64 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 30 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 11.54% |
25.2%
13.7 pts worse
|
Numerator 6 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
2.1
1.3 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.3%
1.2 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.3% · Q3 3.9% · Q4 3.8% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 10.6% |
3.3%
7.3 pts worse
|
5.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 8.5% · Q3 8.2% · Q4 25.0% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.1% |
18.9%
3.2 pts worse
|
19.6%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 21.5% · Q3 16.7% · Q4 26.5% · 4Q avg 22.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.1% |
10.8%
2.3 pts worse
|
16.7%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 12.5% · Q3 13.2% · Q4 15.4% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 35.4% |
15.4%
20 pts worse
|
16.3%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.8% · Q2 33.7% · Q3 17.9% · Q4 49.6% · 4Q avg 35.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 36.2% |
16.1%
20.1 pts worse
|
14.9%
21.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 34.5% · Q3 38.2% · Q4 43.5% · 4Q avg 36.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.5%
1.3 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.4% · Q3 1.2% · Q4 1.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
0.8%
0.9 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.9% · Q3 1.4% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.3% |
15.0%
12.3 pts worse
|
19.8%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 34.5% · Q3 23.1% · Q4 16.3% · 4Q avg 27.3% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.2%
0.2 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 1.6% · Q3 4.7% · Q4 5.8% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.6% |
12.0%
5.6 pts worse
|
12.0%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 17.6% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.5%
1.6 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 3.8% · Q4 3.6% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.7% |
88.0%
4.7 pts better
|
79.7%
13 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
25.9%
0.2 pts better
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 21.6% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-20 · Fire 2023-12-20
8 health deficiencies
Top issue: Resident Rights (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-11-02 · Fire 2022-11-02
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-14
F · Potential for more than minimal harm
2023-12-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
D · Potential for more than minimal harm
2023-12-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-01
D · Potential for more than minimal harm
2023-12-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-01
D · Potential for more than minimal harm
2023-12-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-01
D · Potential for more than minimal harm
2023-12-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-01
F · Potential for more than minimal harm
2022-11-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-05
E · Potential for more than minimal harm
2023-12-20
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-20
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-20
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-01-16
E · Potential for more than minimal harm
2022-11-02
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-12-01
E · Potential for more than minimal harm
2022-11-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-01
E · Potential for more than minimal harm
2022-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-02
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-12-01
Penalties and ownership
What sits behind the stars
Ownership
Chambers County Public Hospital District No. 1
5% Or Greater Direct Ownership Interest · Organization
Bradberry, Tiffani
W-2 Managing Employee · Individual
Cooper, Kimberly
Corporate Director · Individual
Cooriston, Craig
Operational/Managerial Control · Individual
Hemphill SNF Operations LLC
Operational/Managerial Control · Organization
Newton, Elizabeth
Corporate Director · Individual
Nearby options
Other facilities in reach
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Hemphill Care Center
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1-star overall rating with 2-star inspections with $60,212 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Avir At San Augustine
San Augustine, TX
1-star overall rating with 3-star inspections with $102,752 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Stonecreek Nursing & Rehabilitation
San Augustine, TX
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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