Corsicana, TX

Legacy West Rehabilitation And Healthcare

5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

3300 W 2nd Ave, Corsicana, TX

(903) 874-5333

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

148

Certified beds

Average residents

54

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Southwest Ltc

Operator or chain grouping

Approved since

1995-06-16

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

13 facilities

Chain averages 3 overall / 4 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

0.29

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.11

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.20

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.59

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.40

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.89

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.20

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.34

CMS adjusted RN staffing hours

Adjusted total hours

4.25

CMS adjusted total nurse staffing hours

Case-mix index

1.16

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

57%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,800

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

Performance score

31.67

Composite VBP score used to determine payment impact.

Payment multiplier

0.9866

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.59

Baseline 20.09% · Performance 20.23% · Measure score 2.59 · Achievement 2.59 · Improvement 0

Healthcare-associated infections

1.69

Baseline 7.16% · Performance 7.33% · Measure score 1.69 · Achievement 1.69 · Improvement 0

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

5.22

Baseline 4.87 hours · Performance 4.56 hours · Measure score 5.22 · Achievement 5.22 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.02%	10.72% 0.7 pts better	No Different than the National Rate · Eligible stays 91 · Observed rate 8.79% · Lower 95% interval 6.96%
Discharge to community	53.85%	50.57% 3.3 pts better	No Different than the National Rate · Eligible stays 65 · Observed rate 49.23% · Lower 95% interval 42.41%
Medicare spending per beneficiary	0.89	1.02 0.1 pts better
Drug regimen review with follow-up	72.73%	95.27% 22.5 pts worse	Numerator 32 · Denominator 44
Falls with major injury	2.27%	0.77% 1.5 pts worse	Numerator 1 · Denominator 44
Discharge self-care score	61.76%	53.69% 8.1 pts better	Numerator 21 · Denominator 34
Discharge mobility score	70.59%	50.94% 19.7 pts better	Numerator 24 · Denominator 34
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 44 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.33%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 52 · Observed rate 7.69% · Lower 95% interval 4.13%
Staff COVID-19 vaccination coverage	8.82%	8.2% 0.6 pts better	Numerator 6 · Denominator 68
Staff flu vaccination coverage	13.73%	42% 28.3 pts worse	Numerator 14 · Denominator 102
Discharge function score	67.65%	56.45% 11.2 pts better	Numerator 23 · Denominator 34
Transfer of health information to provider	96.55%	95.95% 0.6 pts better	Numerator 28 · Denominator 29
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	25%	25.2% 0.2 pts worse	Numerator 5 · Denominator 20

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.6	2.1 0.5 pts worse	1.9 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 1.6 · Expected 1.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.2	2.1 0.1 pts worse	1.8 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.6 · Expected 1.2 · 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 98.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	92.3%	97.9% 5.6 pts worse	95.5% 3.2 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 92.3%
Percentage of long-stay residents experiencing one or more falls with major injury	9.7%	3.3% 6.4 pts worse	3.3% 6.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 12.0% · Q3 9.4% · Q4 8.0% · 4Q avg 9.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	2.7% 2.7 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	0.0%	3.3% 3.3 pts better	5.4% 5.4 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 received an antianxiety or hypnotic medication	8.2%	18.9% 10.7 pts better	19.6% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 7.7% · Q3 4.9% · Q4 8.1% · 4Q avg 8.2%
Percentage of long-stay residents who received an antipsychotic medication	13.6%	10.8% 2.8 pts worse	16.7% 3.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 12.9% · Q3 11.8% · Q4 15.6% · 4Q avg 13.6% · 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	19.1%	15.4% 3.7 pts worse	16.3% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 19.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	31.7%	16.1% 15.6 pts worse	14.9% 16.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 35.3% · Q3 24.3% · Q4 45.9% · 4Q avg 31.7% · 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	0.5%	0.8% 0.3 pts better	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.0%	15.0% 11 pts worse	19.8% 6.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 27.7% · Q3 29.6% · Q4 24.3% · 4Q avg 26.0%
Percentage of long-stay residents with pressure ulcers	2.6%	4.2% 1.6 pts better	5.1% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.5% · Q3 1.6% · Q4 1.5% · 4Q avg 2.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	95.0%	89.7% 5.3 pts better	81.7% 13.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 92.7% · Q3 93.5% · Q4 100.0% · 4Q avg 95.0%
Percentage of short-stay residents who had an outpatient emergency department visit	20.2%	12.0% 8.2 pts worse	12.0% 8.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 20.6% · Expected 11.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.9%	1.5% 1.4 pts worse	1.6% 1.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.6% · Q3 0.0% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	85.5%	88.0% 2.5 pts worse	79.7% 5.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 85.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	22.6%	25.9% 3.3 pts better	23.9% 1.3 pts better	Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 20.6% · Expected 21.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-21 · Fire 2024-11-21

1 health deficiencies

Top issue: Resident Assessment and Care Planning (1 deficiency)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2023-09-27 · Fire 2023-09-27

1 health deficiencies

Top issue: Resident Rights (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2022-08-11 · Fire 2022-08-11

11 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-11-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-31

D · Potential for more than minimal harm 2024-11-21

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-03-31

F · Potential for more than minimal harm 2023-09-27

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-05-08

F · Potential for more than minimal harm 2023-09-27

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-04-19

F · Potential for more than minimal harm 2023-09-27

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-04-19

F · Potential for more than minimal harm 2023-09-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-06-02

F · Potential for more than minimal harm 2022-08-11

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2022-10-03

F · Potential for more than minimal harm 2022-08-11

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2022-10-03

E · Potential for more than minimal harm 2022-08-11

K344 · Smoke Deficiencies

Fire Safety

Have an alternate power supply for its alarm system.

Corrected 2022-10-03

E · Potential for more than minimal harm 2022-08-11

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2022-10-03

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-11-21

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 2024-12-13

D · Potential for more than minimal harm 2024-02-21

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 2024-03-21

D · Potential for more than minimal harm 2023-12-07

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2023-12-29

E · Potential for more than minimal harm 2023-09-27

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-09-28

E · Potential for more than minimal harm 2022-08-11

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2022-09-20

E · Potential for more than minimal harm 2022-08-11

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2022-09-20

E · Potential for more than minimal harm 2022-08-11

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 2022-09-20