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Legacy Rehabilitation And Living

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About Legacy Rehabilitation And Living

General Information

Legal Business NameStratford Hospital District
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareMarch 29, 2004 (13 years)
Capacity147
Residents91
Percent Occupied62%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Legacy Rehabilitation And Living

Legacy Rehabilitation And Living
was reviewed by Medicare to have a rating of 2 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Texas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

July 28, 2016 - 8 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
FManyPotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
ESomePotential for HarmHealth InspectionKeep residents' personal and medical records private and confidential.

September 14, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FManyPotential for HarmHealth InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
ESomePotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
ESomePotential for HarmHealth InspectionAllow residents to easily view the results of the nursing home's most recent inspection.
ESomePotential for HarmHealth InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
ESomePotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
ESomePotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmHealth InspectionProvide care for each resident in a way that maintains or improves their quality of life.
DFewPotential for HarmHealth InspectionMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
DFewPotential for HarmHealth InspectionReasonably accommodate the needs and preferences of each resident.
DFewPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.

August 3, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaintHave enough nurses to care for every resident in a way that maximizes the resident's well being.

July 31, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 44 days
---Fine$1,658 fine

December 12, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmHealth InspectionMake sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
ESomePotential for HarmHealth InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
ESomePotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
ESomePotential for HarmHealth InspectionAllow residents the right to participate in the planning or revision of care and treatment.
ESomePotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
DFewPotential for HarmHealth InspectionDevelop policies and procedures for influenza and pneumococcal immunizations.
DFewPotential for HarmHealth InspectionGive notice to the resident before a room or roommate change.

November 19, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaintMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

October 9, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.

April 16, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Legacy Rehabilitation And Living require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 15min
2hr 25min
ReportedExpected
CNA
1hr 10min
45min
ReportedExpected
LPN
30min
1hr 15min
ReportedExpected
RN
3hr 55min
4hr 25min
ReportedExpected
Total Nursing

This facility also provides approximately 30min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

63.9%
76.8%
76.8%
76.8%
91.6%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
72.9%
72.4%
93.7%
97.7%
89.8%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
64.5%
48.4%
57.1%
59.0%
48.3%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of low risk long-stay residents who lose control of their bowels or bladder
34.8%
34.2%
35.3%
37.8%
27.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who received an antianxiety or hypnotic medication
9.2%
20.0%
11.2%
14.2%
20.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents whose ability to move independently worsened
25.0%
26.8%
27.0%
24.3%
19.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who received an antipsychotic medication
11.9%
13.7%
17.6%
43.2%
19.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents whose need for help with daily activities has increased
7.5%
2.6%
0.0%
0.0%
7.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who self-report moderate to severe pain
8.2%
4.8%
3.9%
3.6%
6.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who lose too much weight
7.1%
4.3%
8.9%
9.1%
6.3%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of high risk long-stay residents with pressure ulcers
15.4%
9.2%
11.1%
12.6%
4.9%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who have depressive symptoms
2.4%
0.0%
2.6%
1.2%
4.4%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents with a urinary tract infection
3.5%
5.7%
8.9%
5.7%
3.6%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents experiencing one or more falls with major injury
0.9%
0.9%
0.0%
0.0%
2.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
0.0%
0.0%
0.0%
0.4%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

16.9%
52.8%
75.0%
83.6%
74.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
54.1%
86.1%
86.1%
86.1%
71.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
69.7%
65.6%
58.2%
62.2%
55.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents who made improvements in function
14.9%
5.2%
1.4%
0.0%
14.2%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents who self-report moderate to severe pain
0.0%
2.2%
3.5%
3.9%
3.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents who newly received an antipsychotic medication
1.9%
0.0%
0.0%
0.0%
1.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents with pressure ulcers that are new or worsened