Bryan, TX

Legacy Nursing and Rehabilitation

2-star overall rating with 2-star inspections with 18 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

2817 Kent Street, Bryan, TX

(979) 776-7521

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

117

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Legacy Nursing & Rehabilitation

Operator or chain grouping

Approved since

1969-02-07

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

9 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

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

0.19

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.87

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.28

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.34

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.06

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.96

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.12

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.18

CMS adjusted RN staffing hours

Adjusted total hours

3.15

CMS adjusted total nurse staffing hours

Case-mix index

1.45

Higher values indicate more complex resident acuity

RN turnover

20%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,001

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

Performance score

18.36

Composite VBP score used to determine payment impact.

Payment multiplier

0.9820

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 19.25% · Performance 21.47% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

5.51

Baseline 9.11% · Performance 6.64% · Measure score 5.51 · Achievement 4 · Improvement 5.51

Total nurse turnover

1.84

Baseline 58.46% · Performance 56.16% · Measure score 1.84 · Achievement 1.84 · Improvement 0.18

Adjusted total nurse staffing

Baseline 2.87 hours · Performance 2.85 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.87%	10.72% 2.1 pts worse	No Different than the National Rate · Eligible stays 166 · Observed rate 16.27% · Lower 95% interval 10.23%
Discharge to community	38.68%	50.57% 11.9 pts worse	Worse than the National Rate · Eligible stays 133 · Observed rate 29.32% · Lower 95% interval 28.66%
Medicare spending per beneficiary	1.16	1.02 0.1 pts worse
Drug regimen review with follow-up	70.45%	95.27% 24.8 pts worse	Numerator 62 · Denominator 88
Falls with major injury	1.14%	0.77% 0.4 pts worse	Numerator 1 · Denominator 88
Discharge self-care score	33.9%	53.69% 19.8 pts worse	Numerator 20 · Denominator 59
Discharge mobility score	25.42%	50.94% 25.5 pts worse	Numerator 15 · Denominator 59
Pressure ulcers or injuries, new or worsened	2.27%	2.29% About the same	Numerator 2 · Denominator 88 · Adjusted rate 2.12%
Healthcare-associated infections requiring hospitalization	6.64%	7.12% 0.5 pts better	No Different than the National Rate · Eligible stays 102 · Observed rate 6.86% · Lower 95% interval 4.33%
Staff COVID-19 vaccination coverage	53.57%	8.2% 45.4 pts better	Numerator 60 · Denominator 112
Staff flu vaccination coverage	18.75%	42% 23.2 pts worse	Numerator 42 · Denominator 224
Discharge function score	44.07%	56.45% 12.4 pts worse	Numerator 26 · Denominator 59
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 26 · Denominator 26
Transfer of health information to patient	93.94%	96.28% 2.3 pts worse	Numerator 31 · Denominator 33
Resident COVID-19 vaccinations up to date	63.83%	25.2% 38.6 pts better	Numerator 30 · Denominator 47

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.1	2.1 1 pts better	1.9 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.7	2.1 0.4 pts better	1.8 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 1.7 · 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	94.6%	97.9% 3.3 pts worse	95.5% 0.9 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6%
Percentage of long-stay residents experiencing one or more falls with major injury	1.5%	3.3% 1.8 pts better	3.3% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.2% · Q3 1.1% · Q4 1.2% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	7.6%	2.7% 4.9 pts worse	11.4% 3.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 11.8% · Q3 4.8% · Q4 3.8% · 4Q avg 7.6%
Percentage of long-stay residents who lose too much weight	0.4%	3.3% 2.9 pts better	5.4% 5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	18.3%	18.9% 0.6 pts better	19.6% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 23.6% · Q3 17.8% · Q4 13.2% · 4Q avg 18.3%
Percentage of long-stay residents who received an antipsychotic medication	12.4%	10.8% 1.6 pts worse	16.7% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 12.5% · Q3 10.5% · Q4 12.5% · 4Q avg 12.4% · 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	22.9%	15.4% 7.5 pts worse	16.3% 6.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 20.7% · Q3 25.0% · Q4 13.8% · 4Q avg 22.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	17.4%	16.1% 1.3 pts worse	14.9% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 18.8% · Q3 26.2% · Q4 7.0% · 4Q avg 17.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.4%	0.5% 0.9 pts worse	1.0% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 3.1% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.6%	0.8% 0.2 pts better	1.7% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	18.5%	15.0% 3.5 pts worse	19.8% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 20.8% · Q3 9.7% · Q4 20.6% · 4Q avg 18.5%
Percentage of long-stay residents with pressure ulcers	2.7%	4.2% 1.5 pts better	5.1% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.5% · Q3 3.0% · Q4 3.2% · 4Q avg 2.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.5%	89.7% 9.8 pts better	81.7% 17.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.1% · Q3 99.0% · Q4 100.0% · 4Q avg 99.5%
Percentage of short-stay residents who had an outpatient emergency department visit	8.5%	12.0% 3.5 pts better	12.0% 3.5 pts better	Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 8.7% · Expected 11.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.5%	1.5% About the same	1.6% 0.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 4.9% · 4Q avg 1.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	47.1%	88.0% 40.9 pts worse	79.7% 32.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 47.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.9%	25.9% About the same	23.9% 2 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 29.0% · Expected 26.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-08 · Fire 2025-05-08

18 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

1 fire-safety deficiencies

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

Cycle 2 Health 2024-03-29 · Fire 2024-03-29

8 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-01-27 · Fire 2023-01-27

10 health deficiencies

Top issue: Nutrition and Dietary (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-05-08

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-06-18

Inspection history

Recent health citations

G · Actual harm 2026-01-15

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 2026-02-09

E · Potential for more than minimal harm 2025-12-04

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 2025-12-05

D · Potential for more than minimal harm 2025-12-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-12-05

D · Potential for more than minimal harm 2025-06-11

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 2025-07-10

E · Potential for more than minimal harm 2025-05-14

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 2025-06-13

E · Potential for more than minimal harm 2025-05-08

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 2025-06-06

E · Potential for more than minimal harm 2025-05-08

F697 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-06-06

E · Potential for more than minimal harm 2025-05-08

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-06-06

E · Potential for more than minimal harm 2025-05-08

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 2025-06-06