Cycle 1
Health 2025-10-01 · Fire 2025-10-01
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Pollock, LA
Legacy Nursing And Rehabilitation Of Pollock
1-star overall rating with 2-star inspections with $13,020 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
8275 Highway 165, Pollock, LA
(318) 765-3557
Overall
1 / 5
CMS overall stars
Health inspections
2 / 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
103
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-02-13
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
0.21
Registered nurse staffing · state 0.32 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 1.18 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
2.92
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.09
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
0.21
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,663
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.28
Performance 20.84% · Measure score 1.28 · Achievement 1.28 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 8.35% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.89
Baseline 37.26% · Performance 47.76% · Measure score 3.89 · Achievement 3.89 · Improvement 0
Adjusted total nurse staffing
1.15
Baseline 3.56 hours · Performance 3.40 hours · Measure score 1.15 · Achievement 1.15 · Improvement 0
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 44 · Observed rate 6.82% · Lower 95% interval 6.06% |
| Discharge to community | 41.51% |
50.57%
9.1 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 28.57% · Lower 95% interval 29.96% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 26.19% |
95.27%
69.1 pts worse
|
Numerator 22 · Denominator 84 |
| Falls with major injury | 5.95% |
0.77%
5.2 pts worse
|
Numerator 5 · Denominator 84 |
| Discharge self-care score | 48.08% |
53.69%
5.6 pts worse
|
Numerator 25 · Denominator 52 |
| Discharge mobility score | 51.92% |
50.94%
1 pts better
|
Numerator 27 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 3 · Denominator 84 · Adjusted rate 2.79% |
| Healthcare-associated infections requiring hospitalization | 8.35% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 11.36% · Lower 95% interval 4.91% |
| Staff COVID-19 vaccination coverage | 1.2% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 83 |
| Staff flu vaccination coverage | 26.14% |
42%
15.9 pts worse
|
Numerator 23 · Denominator 88 |
| Discharge function score | 55.77% |
56.45%
0.7 pts worse
|
Numerator 29 · Denominator 52 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 39 · Denominator 39 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 15.56% |
25.2%
9.6 pts worse
|
Numerator 7 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.6
0.1 pts better
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.8
1.1 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 | 76.7% |
92.0%
15.3 pts worse
|
93.4%
16.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 90.3% · Q3 66.2% · Q4 64.1% · 4Q avg 76.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 76.8% |
94.9%
18.1 pts worse
|
95.5%
18.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 76.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.4%
0.4 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 1.4% · Q3 2.7% · Q4 2.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.8%
1.8 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 | 3.0% |
5.2%
2.2 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 1.8% · Q3 1.5% · Q4 3.2% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 44.7% |
23.1%
21.6 pts worse
|
19.6%
25.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.1% · Q2 39.0% · Q3 50.0% · Q4 44.9% · 4Q avg 44.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 46.4% |
24.4%
22 pts worse
|
16.7%
29.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.7% · Q2 41.7% · Q3 46.5% · Q4 52.8% · 4Q avg 46.4% · 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 | 17.7% |
22.2%
4.5 pts better
|
16.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.9% · Q2 10.9% · Q3 9.9% · Q4 31.1% · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.7% |
20.1%
3.6 pts worse
|
14.9%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 21.4% · Q3 36.5% · Q4 14.5% · 4Q avg 23.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.6%
0.1 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.6%
2.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.9% |
16.9%
3 pts worse
|
19.8%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 19.7% · Q3 14.3% · Q4 27.1% · 4Q avg 19.9% |
| Percentage of long-stay residents with pressure ulcers | 10.6% |
6.2%
4.4 pts worse
|
5.1%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 10.7% · Q3 8.7% · Q4 11.7% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 37.3% |
83.6%
46.3 pts worse
|
81.7%
44.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 40.3% · Q3 33.9% · Q4 34.0% · 4Q avg 37.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.3% |
14.7%
0.6 pts worse
|
12.0%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 16.9% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
3.3%
0.5 pts better
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 9.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 4.3% |
76.2%
71.9 pts worse
|
79.7%
75.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 4.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.3% |
27.8%
1.5 pts worse
|
23.9%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.3% · Observed 28.8% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-24 · Fire 2024-07-24
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-05-17 · Fire 2023-05-17
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-10-01
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-11-24
D · Potential for more than minimal harm
2024-07-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-10-01
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 2025-10-31
E · Potential for more than minimal harm
2025-10-01
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 2025-10-31
E · Potential for more than minimal harm
2025-10-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-31
D · Potential for more than minimal harm
2025-10-01
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-10-31
D · Potential for more than minimal harm
2025-10-01
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-10-31
D · Potential for more than minimal harm
2025-10-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-31
D · Potential for more than minimal harm
2025-10-01
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-10-31
E · Potential for more than minimal harm
2025-08-25
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-04-02
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 2025-04-07
E · Potential for more than minimal harm
2025-04-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-04-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-04-02
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 2025-04-07
D · Potential for more than minimal harm
2024-11-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-07-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-07-24
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 2024-08-26
E · Potential for more than minimal harm
2024-07-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-24
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 2024-08-26
D · Potential for more than minimal harm
2024-07-24
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-05-15
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 2024-06-26
D · Potential for more than minimal harm
2024-05-15
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-02-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-08
J · Immediate jeopardy
2023-07-19
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 2023-07-20
J · Immediate jeopardy
2023-07-19
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-05-17
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 2023-06-30
D · Potential for more than minimal harm
2023-05-17
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 2023-06-30
D · Potential for more than minimal harm
2023-05-17
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-06-30
Penalties and ownership
What sits behind the stars
$13,020
2023-05-17
Fine
Fine · fine $13,020
Fine
Ownership
Woods Haven Nursing Care & Rehabilitation
5% Or Greater Direct Ownership Interest · Organization
Lipsey, Shannon
5% Or Greater Direct Ownership Interest · Individual
Lipsey, Shannon
Corporate Director · Individual
Lipsey, Wilbur
5% Or Greater Direct Ownership Interest · Individual
Nugent, Debbie
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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2-star overall rating with 3-star inspections with 7 recent health deficiencies
#2
The Oaks Care Center
Pineville, LA
2-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
Hilltop Nursing & Rehabilitation Center
Pineville, LA
1-star overall rating with 1-star inspections with abuse icon flag with $23,265 in total fines with 13 recent health deficiencies
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