Cycle 1
Health 2025-07-01 · Fire 2025-07-01
3 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Comanche, TX
Legacy Estate Long Term Care
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
10133 Hwy 16 N, Comanche, TX
(254) 879-4970
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
62
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2024-05-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.72
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.75
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
5.32
CMS adjusted total nurse staffing hours
Case-mix index
1.06
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · Newly certified or not enough cases to report. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · Newly certified or not enough cases to report. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Newly certified or not enough cases to report. |
| Drug regimen review with follow-up | 82.98% |
95.27%
12.3 pts worse
|
Numerator 39 · Denominator 47 · Based on a shorter reporting period than usual. |
| Falls with major injury | 2.13% |
0.77%
1.4 pts worse
|
Numerator 1 · Denominator 47 · Based on a shorter reporting period than usual. |
| Discharge self-care score | 46.43% |
53.69%
7.3 pts worse
|
Numerator 13 · Denominator 28 · Based on a shorter reporting period than usual. |
| Discharge mobility score | 35.71% |
50.94%
15.2 pts worse
|
Numerator 10 · Denominator 28 · Based on a shorter reporting period than usual. |
| Pressure ulcers or injuries, new or worsened | 8.51% |
2.29%
6.2 pts worse
|
Numerator 4 · Denominator 47 · Adjusted rate 10.01% · Based on a shorter reporting period than usual. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · Newly certified or not enough cases to report. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 53.57% |
56.45%
2.9 pts worse
|
Numerator 15 · Denominator 28 · Based on a shorter reporting period than usual. |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 · Based on a shorter reporting period than usual. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Footnote 9,13 |
| Resident COVID-19 vaccinations up to date | 29.41% |
25.2%
4.2 pts better
|
Numerator 10 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 3.5 · Expected 3.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 3.7 · Expected 2.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
97.1%
0.5 pts worse
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 100.0% · Q3 100.0% · Q4 96.0% · 4Q avg 96.6% |
| 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 | 6.9% |
3.3%
3.6 pts worse
|
3.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 10.0% · Q3 4.4% · Q4 4.0% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.3% |
2.7%
8.6 pts worse
|
11.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 12.5% · Q3 4.9% · Q4 13.0% · 4Q avg 11.3% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
3.3%
1.4 pts worse
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 8.8% · Q3 0.0% · Q4 2.2% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.8% |
18.9%
17.9 pts worse
|
19.6%
17.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 38.9% · Q3 41.0% · Q4 28.9% · 4Q avg 36.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
10.8%
2.5 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 7.7% · Q3 9.1% · Q4 5.4% · 4Q avg 8.3% · 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 | 40.8% |
15.4%
25.4 pts worse
|
16.3%
24.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 40.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.9% |
16.1%
12.8 pts worse
|
14.9%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 25.0% · Q3 36.8% · Q4 18.2% · 4Q avg 28.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
0.8%
0.4 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 2.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
15.0%
12 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 32.2% · Q3 36.0% · Q4 14.4% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.2%
0.2 pts worse
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.7% · Q3 5.7% · Q4 4.6% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.2% |
89.7%
13.5 pts worse
|
81.7%
5.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 71.9% · Q3 69.0% · Q4 82.0% · 4Q avg 76.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.3% |
12.0%
5.3 pts worse
|
12.0%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 15.8% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.9% |
1.5%
3.4 pts worse
|
1.6%
3.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q4 0.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.4% |
88.0%
5.6 pts worse
|
79.7%
2.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 42.1% |
25.9%
16.2 pts worse
|
23.9%
18.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 42.1% · Observed 33.3% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-24 · Fire 2024-05-24
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-08
E · Potential for more than minimal harm
2025-07-01
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-09-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-01
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 2025-08-06
F · Potential for more than minimal harm
2025-07-01
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-08-06
D · Potential for more than minimal harm
2025-07-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-06
Penalties and ownership
What sits behind the stars
Ownership
Stark, Elizabeth
Corporate Officer · Individual
Stark, Elizabeth
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Western Hills Healthcare Residence
Comanche, TX
2-star overall rating with 2-star inspections with $62,078 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Deleon Nursing And Rehabilitation
De Leon, TX
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Lone Star Rehabilitation & Wellness Center
Stephenville, TX
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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