Cycle 1
Health 2025-03-11 · Fire 2025-03-11
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Thibodaux, LA
Legacy Nursing and Rehabilitation of Lafourche
2-star overall rating with 3-star inspections with $24,501 in total fines with 2 recent health deficiencies
1002 Tiger Drive, Thibodaux, LA
(985) 447-2205
Overall
2 / 5
CMS overall stars
Health inspections
3 / 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
72
Certified beds
Average residents
69
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-12-01
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
0.44
Registered nurse staffing · state 0.32 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 1.18 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.22 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,209
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.98
Composite VBP score used to determine payment impact.
Payment multiplier
1.0052
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.66
Baseline 34.92% · Performance 40.54% · Measure score 5.66 · Achievement 5.66 · Improvement 0
Adjusted total nurse staffing
4.53
Baseline 4.07 hours · Performance 4.37 hours · Measure score 4.53 · Achievement 4.53 · Improvement 1.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.96% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 15.79% · Lower 95% interval 8.4% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.44 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 92.31% |
95.27%
3 pts worse
|
Numerator 24 · Denominator 26 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 26 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.45% |
8.2%
2.7 pts worse
|
Numerator 6 · Denominator 110 |
| Staff flu vaccination coverage | 14.29% |
42%
27.7 pts worse
|
Numerator 15 · Denominator 105 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · 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 | 2.9 |
2.6
0.3 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 1.8 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.8
0.9 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
92.0%
2.4 pts better
|
93.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 95.5% · Q3 93.8% · Q4 90.8% · 4Q avg 94.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.9%
5.1 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 | 6.0% |
3.4%
2.6 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.5% · Q3 6.2% · Q4 7.7% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
1.8%
1.1 pts worse
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.3% · Q3 3.3% · Q4 3.3% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.2%
1.2 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 5.7% · Q3 0.0% · Q4 1.9% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.6% |
23.1%
3.5 pts worse
|
19.6%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 26.7% · Q3 23.0% · Q4 25.0% · 4Q avg 26.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.2% |
24.4%
10.2 pts better
|
16.7%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 15.1% · Q3 16.0% · Q4 10.9% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 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 | 38.5% |
22.2%
16.3 pts worse
|
16.3%
22.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.8% · Q2 32.8% · Q3 34.1% · Q4 35.3% · 4Q avg 38.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 41.8% |
20.1%
21.7 pts worse
|
14.9%
26.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 50.0% · Q3 44.1% · Q4 37.3% · 4Q avg 41.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.6%
0.7 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 34.7% |
16.9%
17.8 pts worse
|
19.8%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.2% · Q2 31.5% · Q3 21.0% · Q4 40.9% · 4Q avg 34.7% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
6.2%
0.5 pts better
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 8.9% · Q3 5.2% · Q4 7.6% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.9% |
83.6%
13.7 pts worse
|
81.7%
11.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 69.2% · Q4 78.6% · 4Q avg 69.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.2% |
14.7%
0.5 pts worse
|
12.0%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 14.3% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.6% |
3.3%
2.3 pts worse
|
1.6%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.5% |
27.8%
4.7 pts worse
|
23.9%
8.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.5% · Observed 28.6% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-02-16 · Fire 2023-02-16
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
J · Immediate jeopardy
2025-03-11
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 2025-03-28
D · Potential for more than minimal harm
2025-03-11
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 2025-03-28
D · Potential for more than minimal harm
2024-11-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-13
E · Potential for more than minimal harm
2023-10-04
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 2023-11-21
L · Immediate jeopardy
2023-02-16
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-03-17
L · Immediate jeopardy
2023-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-17
L · Immediate jeopardy
2023-02-16
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-16
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 2023-03-17
D · Potential for more than minimal harm
2023-02-16
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 2023-03-17
Penalties and ownership
What sits behind the stars
$24,501
2025-03-11
Fine
Fine · fine $24,501
Fine
Ownership
Chiasson, Jeanne
Corporate Officer · Individual
Francise, Jamie
Corporate Officer · Individual
Francise, Jamie
W-2 Managing Employee · Individual
Peltier, Stephen
Corporate Officer · Individual
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#3
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