Cycle 1
Health 2024-11-20 · Fire 2024-11-20
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Paris, TX
Legend Healthcare And Rehabilitation - Paris
2-star overall rating with 3-star inspections with $16,149 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
520 Se 8th St, Paris, TX
(903) 737-9820
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2005-01-30
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
0.50
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.71
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.20
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.74
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.37
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
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
9,156
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.75
Baseline 20.75% · Performance 21.08% · Measure score 0.75 · Achievement 0.75 · Improvement 0
Healthcare-associated infections
3.71
Baseline 9.11% · Performance 7.38% · Measure score 3.71 · Achievement 1.53 · Improvement 3.71
Total nurse turnover
5.39
Baseline 35.29% · Performance 41.67% · Measure score 5.39 · Achievement 5.39 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.44 hours · Performance 3.04 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.16% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 148 · Observed rate 15.54% · Lower 95% interval 9.58% |
| Discharge to community | 44.27% |
50.57%
6.3 pts worse
|
No Different than the National Rate · Eligible stays 122 · Observed rate 36.89% · Lower 95% interval 35.58% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 83.91% |
95.27%
11.4 pts worse
|
Numerator 73 · Denominator 87 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 87 |
| Discharge self-care score | 56.6% |
53.69%
2.9 pts better
|
Numerator 30 · Denominator 53 |
| Discharge mobility score | 49.06% |
50.94%
1.9 pts worse
|
Numerator 26 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 87 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.38% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 95 · Observed rate 7.37% · Lower 95% interval 4.11% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 9.92% |
42%
32.1 pts worse
|
Numerator 13 · Denominator 131 |
| Discharge function score | 66.04% |
56.45%
9.6 pts better
|
Numerator 35 · Denominator 53 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 9.43% |
25.2%
15.8 pts worse
|
Numerator 5 · Denominator 53 |
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 3.0 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.1 · Expected 1.9 · 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 | 3.2% |
3.3%
0.1 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.8% · Q3 1.6% · Q4 3.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
2.7%
0.1 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.8% · Q3 2.0% · Q4 1.8% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
3.3%
2.4 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.1% · Q3 7.8% · Q4 3.9% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
18.9%
0.5 pts worse
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 18.0% · Q3 19.2% · Q4 20.4% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
10.8%
4 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 6.2% · Q3 8.5% · Q4 8.2% · 4Q avg 6.8% · 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 | 23.0% |
15.4%
7.6 pts worse
|
16.3%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q3 16.3% · 4Q avg 23.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.2% |
16.1%
11.1 pts worse
|
14.9%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 34.9% · Q3 6.4% · Q4 30.8% · 4Q avg 27.2% · 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 | 18.2% |
15.0%
3.2 pts worse
|
19.8%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.9% · Q2 19.0% · Q3 17.3% · Q4 16.4% · 4Q avg 18.2% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
4.2%
2 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.3% · Q3 1.3% · Q4 2.2% · 4Q avg 2.2% · 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 | 15.9% |
12.0%
3.9 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 15.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 2.3% · Q4 5.6% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.2% |
88.0%
9.2 pts better
|
79.7%
17.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
25.9%
1 pts better
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 23.8% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-12 · Fire 2023-10-12
19 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-17 · Fire 2022-08-17
6 health deficiencies
Top issue: Environmental (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-20
E · Potential for more than minimal harm
2022-08-17
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-09-01
E · Potential for more than minimal harm
2022-08-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-15
J · Immediate jeopardy
2024-11-20
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 2024-11-14
E · Potential for more than minimal harm
2024-11-20
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 2024-12-24
E · Potential for more than minimal harm
2024-11-20
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-12-24
E · Potential for more than minimal harm
2024-11-20
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 2024-12-24
D · Potential for more than minimal harm
2024-11-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-11-20
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-11-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-12-24
F · Potential for more than minimal harm
2023-10-12
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 2023-11-20
E · Potential for more than minimal harm
2023-10-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-10-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-10-12
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 2023-11-20
E · Potential for more than minimal harm
2023-10-12
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 2023-11-20
E · Potential for more than minimal harm
2023-10-12
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 2023-11-20
E · Potential for more than minimal harm
2023-10-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-10-12
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-10-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-10-12
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-12
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 2023-11-20
D · Potential for more than minimal harm
2023-10-12
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 2023-11-20
D · Potential for more than minimal harm
2023-10-12
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 2023-11-20
D · Potential for more than minimal harm
2023-10-12
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 2023-11-20
D · Potential for more than minimal harm
2023-10-12
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 2023-11-20
D · Potential for more than minimal harm
2023-10-12
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 2023-11-20
D · Potential for more than minimal harm
2023-10-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-12
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-12
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-24
D · Potential for more than minimal harm
2022-08-17
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 2022-10-07
D · Potential for more than minimal harm
2022-08-17
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2022-10-07
D · Potential for more than minimal harm
2022-08-17
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-10-07
D · Potential for more than minimal harm
2022-08-17
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-10-07
D · Potential for more than minimal harm
2022-08-17
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2022-10-07
Penalties and ownership
What sits behind the stars
$16,149
2024-11-20
Fine
Fine · fine $16,149
Fine
Ownership
Fannin County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Operational/Managerial Control · Individual
Eiffel Healthcare LLC
Operational/Managerial Control · Organization
Lawrence, Ra
Operational/Managerial Control · Individual
Sanderson, Clark
Corporate Officer · Individual
Nearby options
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#2
Paris Healthcare Center
Paris, TX
3-star overall rating with 2-star inspections with $164,407 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Stillhouse Rehabilitation And Healthcare Center
Paris, TX
3-star overall rating with 3-star inspections with $8,162 in total fines with 19 recent health deficiencies
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