Cycle 1
Health 2025-01-17 · Fire 2025-01-17
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Bullhead City, AZ
The Legacy Rehab & Care Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies
2812 Silver Creek Road, Bullhead City, AZ
(928) 763-1404
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
120
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-01-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.42
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
45%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,508
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.12% · Performance 23.33% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.36% · Performance 7.86% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.23
Performance 54.55% · Measure score 2.23 · Achievement 2.23 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.52
Baseline 3.85 hours · Performance 3.80 hours · Measure score 2.52 · Achievement 2.52 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.57% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 267 · Observed rate 10.86% · Lower 95% interval 7.5% |
| Discharge to community | 61.51% |
50.57%
10.9 pts better
|
Better than the National Rate · Eligible stays 268 · Observed rate 55.6% · Lower 95% interval 54.74% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 153 · Denominator 153 |
| Falls with major injury | 1.31% |
0.77%
0.5 pts worse
|
Numerator 2 · Denominator 153 |
| Discharge self-care score | 35.19% |
53.69%
18.5 pts worse
|
Numerator 38 · Denominator 108 |
| Discharge mobility score | 46.3% |
50.94%
4.6 pts worse
|
Numerator 50 · Denominator 108 |
| Pressure ulcers or injuries, new or worsened | 0.66% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 152 · Adjusted rate 0.89% |
| Healthcare-associated infections requiring hospitalization | 7.86% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 156 · Observed rate 7.69% · Lower 95% interval 4.83% |
| Staff COVID-19 vaccination coverage | 0.67% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 149 |
| Staff flu vaccination coverage | 38.33% |
42%
3.7 pts worse
|
Numerator 69 · Denominator 180 |
| Discharge function score | 48.15% |
56.45%
8.3 pts worse
|
Numerator 52 · Denominator 108 |
| Transfer of health information to provider | 97.37% |
95.95%
1.4 pts better
|
Numerator 74 · Denominator 76 |
| Transfer of health information to patient | 96.77% |
96.28%
0.5 pts better
|
Numerator 60 · Denominator 62 |
| Resident COVID-19 vaccinations up to date | 2.7% |
25.2%
22.5 pts worse
|
Numerator 2 · Denominator 74 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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% |
94.6%
5.4 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 | 5.7% |
2.1%
3.6 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 8.9% · Q3 4.4% · Q4 5.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.2%
4.2 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 | 3.7% |
5.3%
1.6 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.0% · Q3 4.8% · Q4 0.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.4% |
20.5%
15.1 pts better
|
19.6%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 7.0% · Q3 4.7% · Q4 2.8% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
11.8%
3.8 pts worse
|
16.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 20.0% · Q3 12.1% · Q4 10.3% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
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 | 20.2% |
14.5%
5.7 pts worse
|
16.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
10.8%
1.9 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 12.2% · Q3 5.0% · Q4 6.2% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
0.9%
2.1 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 6.2% · Q3 0.0% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.2%
1.2 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 4.5% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.3% |
20.5%
0.8 pts worse
|
19.8%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 24.4% · Q3 21.9% · Q4 15.3% · 4Q avg 21.3% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.8%
1.6 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 6.0% · Q4 2.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.1%
8.4 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 99.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.5% |
10.7%
12.8 pts worse
|
12.0%
11.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 21.4% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.1%
0.7 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
87.3%
11 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.7% |
24.6%
5.1 pts worse
|
23.9%
5.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.7% · Observed 26.5% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-09 · Fire 2023-02-09
2 health deficiencies
Top issue: Environmental (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2021-12-02 · Fire 2021-12-02
3 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-02-09
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-02-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-20
E · Potential for more than minimal harm
2021-12-02
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-01-03
E · Potential for more than minimal harm
2021-12-02
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-01-03
E · Potential for more than minimal harm
2021-12-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-12-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-12-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-12-02
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-01-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-11-01
E · Potential for more than minimal harm
2023-02-09
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-02-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-02-20
E · Potential for more than minimal harm
2021-12-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-12-02
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-12-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-01-03
Penalties and ownership
What sits behind the stars
Ownership
Collins, Jessica
5% Or Greater Direct Ownership Interest · Individual
Collins, Jessica
Operational/Managerial Control · Individual
Collins, Jessica
Corporate Director · Individual
Collins, Jillian
5% Or Greater Direct Ownership Interest · Individual
Collins, Joshua
5% Or Greater Direct Ownership Interest · Individual
Creative Care Inc
5% Or Greater Direct Ownership Interest · Organization
Creative Care Inc
Operational/Managerial Control · Organization
Ernest L Harman Md Zia Way LLC
Operational/Managerial Control · Organization
Harman, Ernest
Operational/Managerial Control · Individual
Lingenfelter, Fred
5% Or Greater Direct Ownership Interest · Individual
Napier, Pierre
Operational/Managerial Control · Individual
Napier, Pierre
Corporate Officer · Individual
Ott, Kristen
Operational/Managerial Control · Individual
Ott, Kristen
Corporate Officer · Individual
Overson, Sara
5% Or Greater Direct Ownership Interest · Individual
Terry, Sandra
5% Or Greater Direct Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Desert Highlands Care Center
Kingman, AZ
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
The Gardens Rehab & Care Center
Kingman, AZ
4-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#3
The Lingenfelter Center
Kingman, AZ
2-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies
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