Greenville, TX

Legend Healthcare And Rehabilitation - Greenville

3-star overall rating with 4-star inspections with 7 recent health deficiencies

2300 Jack Finney Blvd, Greenville, TX

(903) 455-7942

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

126

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

1999-02-11

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

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

0.34

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.05

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.85

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.24

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.39

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.86

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.21

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.13

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.35

CMS adjusted RN staffing hours

Adjusted total hours

3.29

CMS adjusted total nurse staffing hours

Case-mix index

1.35

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

62%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,167

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

Performance score

7.79

Composite VBP score used to determine payment impact.

Payment multiplier

0.9807

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 21.81% · Performance 21.58% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

1.68

Baseline 6.35% · Performance 7.33% · Measure score 1.68 · Achievement 1.68 · Improvement 0

Total nurse turnover

0.79

Baseline 52.38% · Performance 60.44% · Measure score 0.79 · Achievement 0.79 · Improvement 0

Adjusted total nurse staffing

0.64

Baseline 3.07 hours · Performance 3.26 hours · Measure score 0.64 · Achievement 0.64 · Improvement 0.21

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.91%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 173 · Observed rate 11.56% · Lower 95% interval 7.87%
Discharge to community	52.57%	50.57% 2 pts better	No Different than the National Rate · Eligible stays 163 · Observed rate 48.47% · Lower 95% interval 44.47%
Medicare spending per beneficiary	1.11	1.02 0.1 pts worse
Drug regimen review with follow-up	94%	95.27% 1.3 pts worse	Numerator 94 · Denominator 100
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 100
Discharge self-care score	63.64%	53.69% 10 pts better	Numerator 28 · Denominator 44
Discharge mobility score	54.55%	50.94% 3.6 pts better	Numerator 24 · Denominator 44
Pressure ulcers or injuries, new or worsened	2%	2.29% 0.3 pts better	Numerator 2 · Denominator 100 · Adjusted rate 1.9%
Healthcare-associated infections requiring hospitalization	7.33%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 105 · Observed rate 7.62% · Lower 95% interval 4.15%
Staff COVID-19 vaccination coverage	2.08%	8.2% 6.1 pts worse	Numerator 3 · Denominator 144
Staff flu vaccination coverage	19.05%	42% 22.9 pts worse	Numerator 44 · Denominator 231
Discharge function score	68.18%	56.45% 11.7 pts better	Numerator 30 · Denominator 44
Transfer of health information to provider	98.28%	95.95% 2.3 pts better	Numerator 57 · Denominator 58
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 30 · Denominator 30
Resident COVID-19 vaccinations up to date	11.9%	25.2% 13.3 pts worse	Numerator 5 · Denominator 42

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.5	2.1 0.4 pts worse	1.9 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.0 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.5	2.1 1.4 pts worse	1.8 1.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.3 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.0%	3.3% 1.3 pts better	3.3% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.6% · Q3 0.0% · Q4 1.4% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.2%	2.7% 0.5 pts better	11.4% 9.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 3.7% · Q4 1.6% · 4Q avg 2.2%
Percentage of long-stay residents who lose too much weight	2.1%	3.3% 1.2 pts better	5.4% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.3% · Q3 0.0% · Q4 3.5% · 4Q avg 2.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.3%	18.9% 0.4 pts worse	19.6% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 19.4% · Q3 19.7% · Q4 20.0% · 4Q avg 19.3%
Percentage of long-stay residents who received an antipsychotic medication	8.8%	10.8% 2 pts better	16.7% 7.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.8% · Q3 9.1% · Q4 8.9% · 4Q avg 8.8% · 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	18.2%	15.4% 2.8 pts worse	16.3% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 29.9% · Q3 18.7% · Q4 15.2% · 4Q avg 18.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	20.0%	16.1% 3.9 pts worse	14.9% 5.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 19.0% · Q3 19.3% · Q4 21.1% · 4Q avg 20.0% · 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	0.0%	0.8% 0.8 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	20.7%	15.0% 5.7 pts worse	19.8% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 16.0% · Q3 14.8% · Q4 17.7% · 4Q avg 20.7%
Percentage of long-stay residents with pressure ulcers	4.4%	4.2% 0.2 pts worse	5.1% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 6.6% · Q3 3.4% · Q4 2.7% · 4Q avg 4.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	89.7% 10.3 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	8.6%	12.0% 3.4 pts better	12.0% 3.4 pts better	Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 9.2% · Expected 11.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.9%	1.5% 0.6 pts better	1.6% 0.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 1.2% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	99.2%	88.0% 11.2 pts better	79.7% 19.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	37.6%	25.9% 11.7 pts worse	23.9% 13.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 37.6% · Observed 37.9% · Expected 24.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-28 · Fire 2025-08-28

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-05-30 · Fire 2024-05-30

9 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-03-22 · Fire 2023-03-22

16 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-08-28

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 2025-10-06

E · Potential for more than minimal harm 2025-08-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-10-06

D · Potential for more than minimal harm 2025-08-28

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 2025-10-06

D · Potential for more than minimal harm 2025-08-28

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 2025-10-06

D · Potential for more than minimal harm 2025-08-28

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 2025-10-06

D · Potential for more than minimal harm 2025-04-09

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 2024-10-03

D · Potential for more than minimal harm 2025-04-09

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 2024-12-23

D · Potential for more than minimal harm 2025-01-30

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 2025-01-31

E · Potential for more than minimal harm 2024-09-15

F728 · Nursing and Physician Services Deficiencies

Health

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

Corrected 2024-09-16

E · Potential for more than minimal harm 2024-05-30

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 2024-07-22

E · Potential for more than minimal harm 2024-05-30

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 2024-07-22

E · Potential for more than minimal harm 2024-05-30

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 2024-07-22

D · Potential for more than minimal harm 2024-05-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-07-22

D · Potential for more than minimal harm 2024-05-30

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 2024-07-22

D · Potential for more than minimal harm 2024-05-30

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-07-22

D · Potential for more than minimal harm 2024-05-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-07-22

E · Potential for more than minimal harm 2023-09-08

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 2023-09-26

E · Potential for more than minimal harm 2023-03-22

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 2023-04-28

E · Potential for more than minimal harm 2023-03-22

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2023-04-28

E · Potential for more than minimal harm 2023-03-22

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 2023-04-28