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)
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
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
Staffing
Hours and turnover
RN hours / resident day
0.29
Registered nurse staffing
LPN hours / resident day
1.11
Licensed practical nurse staffing
Aide hours / resident day
2.20
Nurse aide staffing
Weekend hours
2.89
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
57%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
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
D · Potential for more than minimal harm
2022-08-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-11
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-11
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-11
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 2022-09-20
D · Potential for more than minimal harm
2022-08-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-20
Penalties and ownership
What sits behind the stars
Ownership
Southwest Ltc, Ltd
5% Or Greater Direct Ownership Interest · Organization
Baronet, Rod
5% Or Greater Indirect Ownership Interest · Individual
Brashier, Craig
5% Or Greater Indirect Ownership Interest · Individual
Hines, Barry
5% Or Greater Indirect Ownership Interest · Individual
Keenan, Kristy
W-2 Managing Employee · Individual
Payne, Ronald
5% Or Greater Indirect Ownership Interest · Individual
Payne, Ronald
Corporate Officer · Individual
Quality Care Givers Inc
5% Or Greater Indirect Ownership Interest · Organization
Ronald R Payne Pc
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
The Village At Heritage Oaks
Corsicana, TX
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
Epic Nursing & Rehabilitation
Corsicana, TX
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $218,280 in total fines with 16 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Twilight Home
Corsicana, TX
4-star overall rating with 4-star inspections with $12,795 in total fines with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out