Amarillo, TX

Legacy Rehabilitation and Living

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

4033 W 51ST Ave, Amarillo, TX

(806) 355-4488

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 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

105

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

2004-03-29

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

329 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 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

0.52

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.04

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.88

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.44

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.56

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.95

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.30

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.15

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.59

CMS adjusted RN staffing hours

Adjusted total hours

3.88

CMS adjusted total nurse staffing hours

Case-mix index

1.21

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

61%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,286

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

Performance score

33.39

Composite VBP score used to determine payment impact.

Payment multiplier

0.9877

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.35

Baseline 20.02% · Performance 20.80% · Measure score 1.35 · Achievement 1.35 · Improvement 0

Healthcare-associated infections

5.07

Baseline 7.30% · Performance 6.32% · Measure score 5.07 · Achievement 5.07 · Improvement 3.76

Total nurse turnover

4.95

Baseline 67.37% · Performance 44.19% · Measure score 4.95 · Achievement 4.77 · Improvement 4.95

Adjusted total nurse staffing

1.98

Baseline 3.70 hours · Performance 3.64 hours · Measure score 1.98 · Achievement 1.98 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.67%	10.72% 0.9 pts worse	No Different than the National Rate · Eligible stays 97 · Observed rate 15.46% · Lower 95% interval 7.75%
Discharge to community	42.11%	50.57% 8.5 pts worse	No Different than the National Rate · Eligible stays 72 · Observed rate 37.5% · Lower 95% interval 32.56%
Medicare spending per beneficiary	1.04	1.02 About the same
Drug regimen review with follow-up	96.88%	95.27% 1.6 pts better	Numerator 62 · Denominator 64
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 64
Discharge self-care score	43.48%	53.69% 10.2 pts worse	Numerator 20 · Denominator 46
Discharge mobility score	34.78%	50.94% 16.2 pts worse	Numerator 16 · Denominator 46
Pressure ulcers or injuries, new or worsened	1.56%	2.29% 0.7 pts better	Numerator 1 · Denominator 64 · Adjusted rate 1.7%
Healthcare-associated infections requiring hospitalization	6.32%	7.12% 0.8 pts better	No Different than the National Rate · Eligible stays 55 · Observed rate 3.64% · Lower 95% interval 3.01%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 151
Staff flu vaccination coverage	26.79%	42% 15.2 pts worse	Numerator 60 · Denominator 224
Discharge function score	43.48%	56.45% 13 pts worse	Numerator 20 · Denominator 46
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	18.18%	25.2% 7 pts worse	Numerator 6 · Denominator 33

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	2.1 0.7 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 2.0 · Expected 2.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.0	2.1 1.1 pts better	1.8 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.3 · Expected 2.1 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.5%	97.1% 2.4 pts better	93.4% 6.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.0% · Q4 98.9% · 4Q avg 99.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	99.1%	97.9% 1.2 pts better	95.5% 3.6 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1%
Percentage of long-stay residents experiencing one or more falls with major injury	4.7%	3.3% 1.4 pts worse	3.3% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 4.2% · Q3 2.1% · Q4 4.2% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.7%	2.7% 2 pts better	11.4% 10.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 1.3% · 4Q avg 0.7%
Percentage of long-stay residents who lose too much weight	0.6%	3.3% 2.7 pts better	5.4% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.1% · Q4 0.0% · 4Q avg 0.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.0%	18.9% 7.9 pts better	19.6% 8.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 9.3% · Q3 8.8% · Q4 12.5% · 4Q avg 11.0%
Percentage of long-stay residents who received an antipsychotic medication	8.5%	10.8% 2.3 pts better	16.7% 8.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.3% · Q3 7.6% · Q4 9.5% · 4Q avg 8.5% · 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	6.7%	15.4% 8.7 pts better	16.3% 9.6 pts better	Long Stay · 2024Q4-2025Q3 · Q2 10.3% · Q3 0.0% · Q4 10.8% · 4Q avg 6.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.8%	16.1% 2.3 pts better	14.9% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 4.5% · Q3 11.0% · Q4 17.5% · 4Q avg 13.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 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	0.8%	0.8% About the same	1.7% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	17.3%	15.0% 2.3 pts worse	19.8% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 15.1% · Q3 13.5% · Q4 18.2% · 4Q avg 17.3%
Percentage of long-stay residents with pressure ulcers	4.9%	4.2% 0.7 pts worse	5.1% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.7% · Q3 4.4% · Q4 3.9% · 4Q avg 4.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.0%	89.7% 4.3 pts better	81.7% 12.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 91.8% · Q3 91.2% · Q4 96.3% · 4Q avg 94.0%
Percentage of short-stay residents who had an outpatient emergency department visit	6.3%	12.0% 5.7 pts better	12.0% 5.7 pts better	Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 8.1% · Expected 14.3% · 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 2.0% · Q2 2.0% · Q3 0.0% · Q4 2.1% · 4Q avg 1.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	89.8%	88.0% 1.8 pts better	79.7% 10.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 89.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.0%	25.9% 4.9 pts better	23.9% 2.9 pts better	Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 25.8% · Expected 29.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-31 · Fire 2025-07-31

4 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 2 Health 2024-06-07 · Fire 2024-06-07

7 health deficiencies

Top issue: Resident Rights (3 deficiencies)

1 fire-safety deficiencies

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

Cycle 3 Health 2023-04-14 · Fire 2023-04-14

9 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-07-31

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-08-31

E · Potential for more than minimal harm 2025-07-31

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-09-13

F · Potential for more than minimal harm 2024-06-07

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-07-17

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-21

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2026-01-23

E · Potential for more than minimal harm 2025-09-09

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-09-10

E · Potential for more than minimal harm 2025-07-31

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2025-09-13

E · Potential for more than minimal harm 2025-07-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-13

D · Potential for more than minimal harm 2025-02-04

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 2025-02-02

E · Potential for more than minimal harm 2024-06-07

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 2024-07-17

E · Potential for more than minimal harm 2024-06-07

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 2024-07-17

D · Potential for more than minimal harm 2024-06-07

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 2024-07-17

D · Potential for more than minimal harm 2024-06-07

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 2024-07-17

D · Potential for more than minimal harm 2024-06-07

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-07-17

E · Potential for more than minimal harm 2024-05-17

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2024-06-07

D · Potential for more than minimal harm 2023-09-06

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 2023-10-20

F · Potential for more than minimal harm 2023-04-14

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 2023-05-26

E · Potential for more than minimal harm 2023-04-14