Fort Smith, AR

Legacy Health And Rehabilitation Center

2-star overall rating with 2-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

3310 North 50th Street, Fort Smith, AR

(479) 783-3101

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

115

Certified beds

Average residents

109

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Nhs Management

Operator or chain grouping

Approved since

1995-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

43 facilities

Chain averages 3 overall / 3 health / 4 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

0.37

Registered nurse staffing · state 0.40 · national 0.68

LPN hours / resident day

0.69

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.79

Nurse aide staffing · state 2.72 · national 2.35

Total nurse hours

3.86

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

1.07

RN + LPN hours · state 1.35 · national 1.54

Weekend hours

3.46

Weekend nurse staffing · state 3.48 · national 3.43

Weekend RN hours

0.18

Weekend registered nurse coverage · state 0.27 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.03 · national 0.07

Adjusted RN hours

0.47

CMS adjusted RN staffing hours

Adjusted total hours

4.88

CMS adjusted total nurse staffing hours

Case-mix index

1.08

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 48% · national 45%

Total nurse turnover

49%

Annual nurse turnover · state 51% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,588

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

16.16

Composite VBP score used to determine payment impact.

Payment multiplier

0.9816

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.42

Baseline 22.71% · Performance 21.62% · Measure score 1.42 · Achievement 0 · Improvement 1.42

Healthcare-associated infections

0

Baseline 5.28% · Performance 8.71% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

0

Performance 62.24% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

5.05

Baseline 3.67 hours · Performance 4.51 hours · Measure score 5.05 · Achievement 5.05 · Improvement 3.50

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 10.09%
10.72%
0.6 pts better
No Different than the National Rate · Eligible stays 78 · Observed rate 8.97% · Lower 95% interval 6.74%
Discharge to community 37.42%
50.57%
13.1 pts worse
Worse than the National Rate · Eligible stays 46 · Observed rate 21.74% · Lower 95% interval 26.56%
Medicare spending per beneficiary 0.98
1.02
About the same
Drug regimen review with follow-up 97.92%
95.27%
2.7 pts better
Numerator 47 · Denominator 48
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 48
Discharge self-care score 58.33%
53.69%
4.6 pts better
Numerator 14 · Denominator 24
Discharge mobility score 58.33%
50.94%
7.4 pts better
Numerator 14 · Denominator 24
Pressure ulcers or injuries, new or worsened 6.25%
2.29%
4 pts worse
Numerator 3 · Denominator 48 · Adjusted rate 6.14%
Healthcare-associated infections requiring hospitalization 8.71%
7.12%
1.6 pts worse
No Different than the National Rate · Eligible stays 46 · Observed rate 15.22% · Lower 95% interval 4.75%
Staff COVID-19 vaccination coverage 0%
8.2%
8.2 pts worse
Numerator 0 · Denominator 93
Staff flu vaccination coverage 85.82%
42%
43.8 pts better
Numerator 121 · Denominator 141
Discharge function score 70.83%
56.45%
14.4 pts better
Numerator 17 · Denominator 24
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date Not Available
25.2%
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.2
2.0
0.2 pts worse
1.9
0.3 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 4.6
2.2
2.4 pts worse
1.8
2.8 pts worse
Long Stay · 20240701-20250630 · Adjusted 4.6 · Observed 4.8 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 85.5%
94.9%
9.4 pts worse
93.4%
7.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 80.2% · Q4 64.4% · 4Q avg 85.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 95.4%
96.1%
0.7 pts worse
95.5%
0.1 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.4%
Percentage of long-stay residents experiencing one or more falls with major injury 3.4%
3.9%
0.5 pts better
3.3%
0.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.9% · Q3 2.8% · Q4 6.7% · 4Q avg 3.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 1.5%
1.4%
0.1 pts worse
11.4%
9.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5%
Percentage of long-stay residents who lose too much weight 7.3%
4.9%
2.4 pts worse
5.4%
1.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.4% · Q3 8.8% · Q4 8.7% · 4Q avg 7.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 28.0%
21.8%
6.2 pts worse
19.6%
8.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 31.2% · Q3 28.7% · Q4 24.7% · 4Q avg 28.0%
Percentage of long-stay residents who received an antipsychotic medication 30.2%
12.5%
17.7 pts worse
16.7%
13.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 39.2% · Q2 30.0% · Q3 24.5% · Q4 27.3% · 4Q avg 30.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.1%
0.1 pts better
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 9.3%
11.4%
2.1 pts better
16.3%
7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 9.0% · Q3 7.1% · Q4 6.6% · 4Q avg 9.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 9.2%
10.4%
1.2 pts better
14.9%
5.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 11.4% · Q3 5.7% · Q4 14.3% · 4Q avg 9.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.6%
0.7%
0.1 pts better
1.0%
0.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 1.5%
1.1%
0.4 pts worse
1.7%
0.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 2.9% · Q4 1.0% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 7.8%
14.6%
6.8 pts better
19.8%
12 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 13.7% · Q3 5.6% · Q4 7.6% · 4Q avg 7.8%
Percentage of long-stay residents with pressure ulcers 4.9%
4.6%
0.3 pts worse
5.1%
0.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 8.0% · Q3 3.6% · Q4 5.0% · 4Q avg 4.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 82.1%
81.8%
0.3 pts better
81.7%
0.4 pts better
Short Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 88.0% · Q3 66.7% · Q4 60.6% · 4Q avg 82.1%
Percentage of short-stay residents who had an outpatient emergency department visit 12.4%
13.8%
1.4 pts better
12.0%
0.4 pts worse
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 15.2% · Expected 13.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 5.4%
1.4%
4 pts worse
1.6%
3.8 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.3% · 4Q avg 5.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 76.5%
77.9%
1.4 pts worse
79.7%
3.2 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 38.4%
25.2%
13.2 pts worse
23.9%
14.5 pts worse
Short Stay · 20240701-20250630 · Adjusted 38.4% · Observed 36.4% · Expected 22.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-31 · Fire 2025-01-31

5 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

4 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 2 Health 2024-03-21 · Fire 2024-03-21

15 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2022-12-30 · Fire 2022-12-30

17 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-31

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-03-02

F · Potential for more than minimal harm 2025-01-31

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-03-02

F · Potential for more than minimal harm 2025-01-31

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-03-02

E · Potential for more than minimal harm 2025-01-31

K344 · Smoke Deficiencies

Fire Safety

Have an alternate power supply for its alarm system.

Corrected 2025-03-02

F · Potential for more than minimal harm 2024-03-21

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 2024-04-20

F · Potential for more than minimal harm 2024-03-21

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-04-20

F · Potential for more than minimal harm 2022-12-30

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-02-07

F · Potential for more than minimal harm 2022-12-30

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-02-07

E · Potential for more than minimal harm 2022-12-30

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2023-02-07

E · Potential for more than minimal harm 2022-12-30

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 2023-02-07

E · Potential for more than minimal harm 2022-12-30

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2023-02-07

E · Potential for more than minimal harm 2022-12-30

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-02-07

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-01-31

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-03-02

E · Potential for more than minimal harm 2025-01-31

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2025-03-02

E · Potential for more than minimal harm 2025-01-31

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 2025-03-02

E · Potential for more than minimal harm 2025-01-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-02

D · Potential for more than minimal harm 2025-01-31

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2025-03-02

D · Potential for more than minimal harm 2025-01-31

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 2025-03-02

D · Potential for more than minimal harm 2025-01-31

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-03-02

D · Potential for more than minimal harm 2025-01-31

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2025-03-02

E · Potential for more than minimal harm 2024-03-21

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 2024-04-20

E · Potential for more than minimal harm 2024-03-21

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 2024-04-20

E · Potential for more than minimal harm 2024-03-21

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-04-20

E · Potential for more than minimal harm 2024-03-21

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 2024-04-20

E · Potential for more than minimal harm 2024-03-21

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 2024-04-20

E · Potential for more than minimal harm 2024-03-21

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2024-04-20

E · Potential for more than minimal harm 2024-03-21

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-04-20

E · Potential for more than minimal harm 2024-03-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-20

E · Potential for more than minimal harm 2024-03-21

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-04-20

E · Potential for more than minimal harm 2024-03-21

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2024-04-20

D · Potential for more than minimal harm 2024-03-21

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-04-20

D · Potential for more than minimal harm 2024-03-21

F688 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-04-20

E · Potential for more than minimal harm 2023-06-21

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2023-07-21

E · Potential for more than minimal harm 2023-06-02

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-07-02

E · Potential for more than minimal harm 2023-03-09

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2023-04-07

F · Potential for more than minimal harm 2022-12-30

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 2023-02-07

E · Potential for more than minimal harm 2022-12-30

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 2023-02-07

E · Potential for more than minimal harm 2022-12-30

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2023-02-07

E · Potential for more than minimal harm 2022-12-30

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-02-07

E · Potential for more than minimal harm 2022-12-30

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-02-07

E · Potential for more than minimal harm 2022-12-30

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2023-02-07

E · Potential for more than minimal harm 2022-12-30

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-02-07

E · Potential for more than minimal harm 2022-12-30

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-02-07

E · Potential for more than minimal harm 2022-12-30

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2023-02-07

E · Potential for more than minimal harm 2022-12-30

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2023-02-07

D · Potential for more than minimal harm 2022-12-30

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-02-07

D · Potential for more than minimal harm 2022-12-30

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 2023-02-07

D · Potential for more than minimal harm 2022-12-30

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 2023-02-07

D · Potential for more than minimal harm 2022-12-30

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2023-02-07

Penalties and ownership

What sits behind the stars

Ownership

Estes, James

5% Or Greater Direct Ownership Interest · Individual

92% 45 facilities 2003-12-31
Estes, James

Corporate Officer · Individual

0% 45 facilities 1997-09-29
Gallagher, Beverly

Operational/Managerial Control · Individual

0% 5 facilities 2023-08-21
Gallagher, Beverly

Corporate Director · Individual

0% 5 facilities 2023-08-21
James Norman Estes Jr Tr

5% Or Greater Direct Ownership Interest · Organization

0% 42 facilities 2006-12-31
Jennifer Lee Estes Tr 031093

5% Or Greater Direct Ownership Interest · Organization

0% 42 facilities 2006-12-31
Long, Phillip

Corporate Officer · Individual

0% 46 facilities 2019-10-01
Moore, Marcia

Operational/Managerial Control · Individual

0% 5 facilities 2024-08-05
Rasco, Lynn

Operational/Managerial Control · Individual

0% 45 facilities 2022-07-01
Rasco, Lynn

Corporate Director · Individual

0% 45 facilities 2022-07-01
Regions Bank

5% Or Greater Security Interest · Organization

0% 53 facilities 2013-08-27
Taylor, Jamie

Operational/Managerial Control · Individual

0% 1 facilities 2024-09-02
White, Holly

Operational/Managerial Control · Individual

0% 5 facilities 2022-03-04
White, Holly

Corporate Director · Individual

0% 5 facilities 2022-03-04

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