Cycle 1
Health 2025-07-09 · Fire 2025-07-09
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Winnsboro, LA
Legacy Nursing And Rehabilitation Of Winnsboro
2-star overall rating with 2-star inspections with $168,036 in total fines with 11 recent health deficiencies
804 Polk Street, Winnsboro, LA
(318) 435-6116
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
84
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Nursing & Rehabilitation
Operator or chain grouping
Approved since
1996-11-01
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
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
0.24
Registered nurse staffing · state 0.32 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 1.18 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.10
Weekend registered nurse coverage · state 0.22 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.26
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
56%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,991
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.1
Composite VBP score used to determine payment impact.
Payment multiplier
0.9863
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.49
Baseline 24.34% · Performance 21.42% · Measure score 3.49 · Achievement 0 · Improvement 3.49
Healthcare-associated infections
0
Baseline 8.04% · Performance 9.58% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.67
Baseline 37.93% · Performance 44.59% · Measure score 4.67 · Achievement 4.67 · Improvement 0
Adjusted total nurse staffing
4.28
Baseline 4.89 hours · Performance 4.29 hours · Measure score 4.28 · Achievement 4.28 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.5% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 10.84% · Lower 95% interval 7.32% |
| Discharge to community | 40.11% |
50.57%
10.5 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 32.14% · Lower 95% interval 28.55% |
| Medicare spending per beneficiary | 1.35 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 87 · Denominator 87 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 87 |
| Discharge self-care score | 69.39% |
53.69%
15.7 pts better
|
Numerator 34 · Denominator 49 |
| Discharge mobility score | 61.22% |
50.94%
10.3 pts better
|
Numerator 30 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 2.3% |
2.29%
About the same
|
Numerator 2 · Denominator 87 · Adjusted rate 2.43% |
| Healthcare-associated infections requiring hospitalization | 9.58% |
7.12%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 15.69% · Lower 95% interval 5.87% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 139 |
| Staff flu vaccination coverage | 4.1% |
42%
37.9 pts worse
|
Numerator 5 · Denominator 122 |
| Discharge function score | 75.51% |
56.45%
19.1 pts better
|
Numerator 37 · Denominator 49 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 96% |
96.28%
0.3 pts worse
|
Numerator 24 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 48.98% |
25.2%
23.8 pts better
|
Numerator 24 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.6
0.4 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.9 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.8
0.7 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.6 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
92.0%
6.4 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 96.4% · Q3 100.0% · Q4 100.0% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
94.9%
2.8 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.4%
1.8 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.4% · Q3 0.0% · Q4 1.3% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
1.8%
0.7 pts worse
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 1.5% · Q4 2.9% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 10.0% |
5.2%
4.8 pts worse
|
5.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 7.1% · Q3 16.7% · Q4 11.8% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.6% |
23.1%
1.5 pts worse
|
19.6%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 23.6% · Q3 23.6% · Q4 22.9% · 4Q avg 24.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.0% |
24.4%
4.6 pts worse
|
16.7%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 31.0% · Q3 28.6% · Q4 23.1% · 4Q avg 29.0% · 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 | 14.5% |
22.2%
7.7 pts better
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 14.8% · Q3 10.1% · Q4 18.1% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
20.1%
7.2 pts better
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 10.8% · Q3 11.1% · Q4 13.3% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.6%
1.6 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 | 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 | 25.5% |
16.9%
8.6 pts worse
|
19.8%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.7% · Q2 22.4% · Q3 24.0% · Q4 23.0% · 4Q avg 25.5% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
6.2%
1.6 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.4% · Q3 4.6% · Q4 4.4% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
83.6%
10.9 pts better
|
81.7%
12.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.3% · Q2 92.6% · Q3 98.3% · Q4 98.0% · 4Q avg 94.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
14.7%
7.9 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 8.8% · Expected 14.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
3.3%
3.3 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.0% |
76.2%
1.2 pts worse
|
79.7%
4.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
27.8%
8.4 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 26.5% · Expected 32.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-15 · Fire 2024-05-15
12 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-28 · Fire 2023-06-28
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-05-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-06-21
E · Potential for more than minimal harm
2023-06-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-25
E · Potential for more than minimal harm
2023-06-28
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-06-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-09
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 2025-08-04
E · Potential for more than minimal harm
2025-07-09
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-08-04
E · Potential for more than minimal harm
2025-07-09
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 2025-08-04
E · Potential for more than minimal harm
2025-07-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-08-04
D · Potential for more than minimal harm
2025-07-09
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 2025-08-04
D · Potential for more than minimal harm
2025-07-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-04
D · Potential for more than minimal harm
2025-07-09
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 2025-08-04
D · Potential for more than minimal harm
2025-07-09
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 2025-08-04
D · Potential for more than minimal harm
2025-07-09
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 2025-08-04
D · Potential for more than minimal harm
2025-07-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-04
D · Potential for more than minimal harm
2025-07-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-04
D · Potential for more than minimal harm
2024-11-14
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 2024-12-02
H · Actual harm
2024-05-15
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 2024-06-12
E · 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 2024-06-12
E · Potential for more than minimal harm
2024-05-15
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 2024-06-12
D · Potential for more than minimal harm
2024-05-15
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 2024-06-12
D · Potential for more than minimal harm
2024-05-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-05-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-05-07
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 2024-06-12
D · Potential for more than minimal harm
2024-05-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-15
G · Actual harm
2024-02-15
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 2024-03-08
D · Potential for more than minimal harm
2024-02-15
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
D · Potential for more than minimal harm
2024-02-15
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 2024-03-08
G · Actual harm
2023-08-17
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 2023-08-09
D · Potential for more than minimal harm
2023-06-28
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 2023-07-14
Penalties and ownership
What sits behind the stars
$151,769
2024-05-07
Fine
Fine · fine $151,769
Fine
$8,824
2024-02-15
Fine
Fine · fine $8,824
Fine
$7,443
2023-08-17
Fine
Fine · fine $7,443
Fine
Ownership
Dgprejean, LLC
5% Or Greater Direct Ownership Interest · Organization
Gum, John
5% Or Greater Indirect Ownership Interest · Individual
Gum, Victor
5% Or Greater Indirect Ownership Interest · Individual
Gum, Victor
Corporate Director · Individual
Holyfield, Myles
5% Or Greater Indirect Ownership Interest · Individual
Jdgum, LLC
5% Or Greater Direct Ownership Interest · Organization
Legacy Management Group, LLC
Operational/Managerial Control · Organization
Mylesh, LLC
5% Or Greater Direct Ownership Interest · Organization
Prejean, Danielle
5% Or Greater Indirect Ownership Interest · Individual
Thornton, Henry
Operational/Managerial Control · Individual
Thornton, Henry
W-2 Managing Employee · Individual
Vdg LLC
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Plantation Manor Nursing And Rehab Center, LLC
Winnsboro, LA
3-star overall rating with 4-star inspections with 4 recent health deficiencies
#2
Mary Anna Nursing Home
Wisner, LA
3-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
Plantation Oaks Nursing & Rehabilitation Center
Wisner, LA
2-star overall rating with 2-star inspections with $128,001 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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