C

LEGACY MANOR NURSING AND REHABILITATION CENTER

1935 NORTH THEOBOLD EXTENSION, GREENVILLE, MS 38704
Score: 66 / 100

Legacy Manor Nursing And Rehabilitation Center is an average performer in CMS ratings, earning a C grade with a score of 66/100. Located in Greenville, Mississippi, the facility meets baseline standards across most quality metrics.

Staffing at Legacy Manor Nursing And Rehabilitation Center is near the national average, with 3.53 total nursing hours per resident per day (national average: 3.8 hours).

Recent CMS inspections identified 18 deficiencies at Legacy Manor Nursing And Rehabilitation Center, including 3 classified as serious — among the most concerning citation levels. The most notable finding involved: protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody..

Score Breakdown

Overall CMS Rating 32 / 40 pts
4 ★ CMS rating
Health Inspections 15 / 25 pts
3 ★ inspection rating
Staffing 16 / 20 pts
4 ★ staffing rating
Quality Measures 15 / 15 pts
5 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 3.53 3.8 Average
Registered Nurses (RN) 0.50 0.7 Below Average
Licensed Practical Nurses (LPN) 1.07 0.7 Above Average
Certified Nursing Assistants (CNA) 1.96 2.4 Below Average
Weekend Total Nursing 3.17 3.8 Below Average
Weekend RN Hours 0.29 0.7 Below Average

🔍 Inspection & Deficiency History

18
Total Deficiencies
Jan 13, 2025
Most Recent Inspection
🟠 15 Moderate 🔴 3 Serious
View recent deficiencies (5 shown)
  • Tag 0600 Severity J
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    Jan 13, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
  • Tag 0656 Severity J
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    Sep 8, 2024 · Resident Assessment and Care Planning Deficiencies
  • Tag 0678 Severity J
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advanc
    Sep 8, 2024 · Quality of Life and Care Deficiencies
  • Tag 0584 Severity D
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for d
    Jun 12, 2024 · Resident Rights Deficiencies
  • Tag 0656 Severity D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    Jun 12, 2024 · Resident Assessment and Care Planning Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 8.5% 4.5% Worse
Falls with major injury 1.0% 3.0% Better
On antipsychotic medication 0.0% 14.5% Better
Urinary tract infections 0.0% 2.5% Better
ADL decline (daily activities) 4.0% 14.0% Better
Excessive weight loss 3.3% 7.5% Better
New/worsened incontinence 6.9% 45.0% Better

⚠️ Penalties & Fines

2 penalties recorded by CMS

Total fines: $27,024

How This Grade Was Calculated

This facility's grade of C is based on a score of 66 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 4★ → 32 pts (max 40)
  • Health Inspection Rating: 3★ → 15 pts (max 25)
  • Staffing Rating: 4★ → 16 pts (max 20)
  • Quality Measures Rating: 5★ → 15 pts (max 15)
  • Penalty deductions: -10 pts
  • Fine deductions: -2 pts

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
For profit - Limited Liability company
Certified Beds
60
Provider Type
Medicare and Medicaid
Resident Council
No
Family Council
No
Sprinkler System
Yes
Last Inspection
Jun 12, 2024
Deficiencies (Cycle 1)
3