Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legacy Nursing And Rehabilitation Of Tallulah during CMS and state inspections, most recent first.
A resident with diabetes had a sliding scale insulin order for 2 units when blood glucose was 150 to 199, but the MAR showed multiple readings in that range with no insulin administered. The NP and DON confirmed the resident should have received 2 units for those blood sugar results.
PRN psychotropic use was not properly limited for a resident with depression, anxiety, and dementia. The resident had an order for PRN Ativan via PEG tube for agitation, but the consultant noted the order needed a prescriber review after 14 days and required documentation of the rationale and a specific duration. The record lacked that documentation, and the DON confirmed there was no documented rationale or duration for the PRN Ativan order.
Pharmacist failed to identify an irregularity in the monthly DRR for a resident receiving Ergocalciferol for vitamin deficiency. The resident’s chart lacked evidence of the ordered q6mo Vitamin D level, and the DON confirmed the missed lab monitoring was not identified on the DRR.
Failure to Obtain Ordered Vitamin D Lab: A resident with cerebral palsy, anxiety, and vitamin deficiency was ordered Ergocalciferol and a Vitamin D level every 6 months, but the record showed no documented Vitamin D level was obtained as ordered. The DON confirmed the lab had not been completed.
A resident’s medication pass included two errors that resulted in a 7% medication error rate. An LPN used a teaspoon to measure Miralax instead of the ordered 17 g dose method and did not administer the ordered Senna 8.6 mg by mouth during the morning med pass; the LPN confirmed both errors, and the DON was notified.
The facility failed to report an injury of unknown origin with serious bodily injury to the State Survey Agency as required by its abuse reporting policy and state law. A cognitively impaired resident with multiple diagnoses, including dementia and a history of repeated falls, was found with bruising and swelling to the lower leg and later diagnosed by x-ray with acute fractures of the tibia and fibula. The resident could not explain the cause of the injury, and the facility’s investigation did not identify a cause, meeting the policy’s definition of an injury of unknown origin. Despite this, the Administrator, who was responsible for such notifications, did not report the incident to the State Survey Agency.
A resident with moderate cognitive impairment and multiple diagnoses underwent an x-ray of the right shoulder/arm, which was reviewed and signed by an LPN. However, there was no documented evidence that the responsible party was notified of the x-ray results in a timely manner, as confirmed by the DON.
A facility failed to assess the effectiveness and necessity of a safety device for a resident with cognitive impairment and multiple diagnoses. The resident was observed on a mattress with raised edges, but the safety device assessment did not include this intervention. Interviews with the DON and an LPN confirmed the omission.
A facility failed to provide adequate activities for a resident with blindness, who reported not being informed of upcoming activities and expressed dissatisfaction with the activities provided. Despite having a monthly activity calendar and attending some events, the resident rated their satisfaction as a 2 out of 10. The Activity Director confirmed the resident was not individually informed of activities.
The facility failed to follow proper procedures for bed rail use for four residents, lacking physician's orders, informed consent, and risk assessments. Residents with cognitive and physical impairments were observed with bed rails installed without necessary documentation, confirmed by the DON.
A facility failed to monitor a resident's medication regimen for bleeding while on anticoagulant therapy. The resident, with a history of cerebral and heart conditions, was prescribed Eliquis and Aspirin. Despite a care plan indicating a risk for bleeding and the need for monitoring, there was no documentation of such monitoring. Interviews with the DON and an LPN confirmed the absence of documentation.
The facility was found to have several food safety and storage deficiencies, including storing clean pots on a shelf with old food particles, a buildup of an unknown substance in the ice machine, improperly sealed food items in the freezer, and bottled water stored directly on the floor. These issues were confirmed by the Dietary Manager and reported to the administrator, affecting the 84 residents receiving meal trays.
The facility failed to maintain a sanitary environment in the kitchen, as personal belongings were improperly stored near food preparation areas, risking cross-contamination. Observations revealed a purse and jacket in contact with food items, and additional personal items in a storage room. The Dietary Manager confirmed these practices were against protocol, affecting meal service for 84 residents.
The facility failed to maintain safe mechanical equipment in the kitchen, with metal shavings on the can opener and grease buildup in the deep fryer. The Dietary Manager confirmed these conditions, which could affect the 84 residents receiving meal trays. The Administrator was notified of these findings.
A resident with a wedge compression fracture of the T11-T12 vertebra was unable to activate his call light due to physical disabilities, as he could not move his left arm or right fingers. This deficiency was confirmed during an interview and a room visit by the DON and a surveyor.
A resident with severe cognitive impairment and high elopement risk left the facility unnoticed after a sitter mistakenly opened an emergency exit door. The resident was found outside by an LPN and returned safely without injuries. The facility failed to report the incident to the State Survey Agency as required by policy.
A resident with dementia and high elopement risk exited a facility unnoticed due to a sitter's mistake and lack of an alert system on an exit door. The resident, wearing a wander guard, was mistaken for a visitor and allowed to leave. An LPN quickly retrieved the resident with a neighbor's help, and the resident returned unharmed. The facility's staff confirmed the deficiency, noting the absence of a code alert system on the exit door.
Two residents in the facility received medications contrary to physician orders, with nurses failing to adhere to prescribed blood pressure and insulin parameters. One resident with diabetes and hypertension was given Lisinopril and insulin without following the specified hold parameters, while another resident received Metoprolol Tartrate despite vital signs indicating it should be held. These deficiencies were confirmed through MAR reviews and staff interviews.
A resident with multiple health issues, including diabetes and blindness, did not receive adequate personal hygiene care. Observations revealed a buildup of crust and moisture between the toes, an odor from the left foot, and untrimmed nasal hairs. A CNA and LPN confirmed these findings, and the DON acknowledged the need for better hygiene practices.
Insulin Not Given Per Sliding Scale Order
Penalty
Summary
The facility failed to ensure competent nursing staff provided nursing and related services to attain or maintain the highest practical physical, mental, and psychosocial well-being of a resident by failing to administer insulin as ordered. Resident #56 was admitted on 11/20/2025 with a diagnosis that included diabetes, and the 2026 physician orders directed insulin on a sliding scale. The sliding scale required 2 units of insulin when blood glucose ranged from 150 to 199. Review of the April 2026 MAR showed multiple blood glucose results in that range, including 182, 152, 170, 162, 169, 172, 186, and 197, and no insulin was given as ordered for those readings. During interviews on 04/22/2026, the Nurse Practitioner confirmed the sliding scale began at 150 and that 2 units should have been administered for blood sugars between 150 and 199, and the DON also confirmed the resident should have received 2 units on those days.
PRN Psychotropic Order Not Limited to 14 Days
Penalty
Summary
The facility failed to ensure that a resident with an order for a PRN psychotropic medication was not subjected to chemical restraint use and failed to limit the PRN psychotropic order to 14 days for Resident #2. Resident #2 was admitted on 08/08/2025 and readmitted on 12/03/2025 with diagnoses including major depressive disorder, anxiety disorder, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and metabolic encephalopathy. The resident’s physician orders included Lorazepam/Ativan 1 mg via PEG tube every 4 hours as needed for agitation related to anxiety disorder. A pharmaceutical consultant report dated 01/19/2026 stated that PRN psychotropic medication is limited to 14 days and required the prescriber to evaluate the resident before extending the order, document the rationale for the extended time period in the medical record, and indicate a specific duration. The report found that S4NP failed to document the rationale for extending the order and failed to indicate a specific duration, and S2DON confirmed there was no documented evidence of a rationale for the PRN Lorazepam/Ativan use or a specific duration.
Pharmacist Failed to Identify Missing Vitamin D Monitoring
Penalty
Summary
The facility failed to ensure the pharmacist identified an irregularity related to monitoring of a prescribed medication for Resident #14, who was admitted with diagnoses including cerebral palsy, anxiety, and vitamin deficiency. The care plan included administering medications as ordered and drawing labs as ordered by the physician. Physician orders included Ergocalciferol (Vitamin D2) 1.25 mg by mouth every Friday for vitamin deficiency and an order to obtain a Vitamin D level every six months. The medical record contained no documented evidence that a Vitamin D level was obtained every six months as ordered, and the monthly Drug Regimen Review dated 03/18/2026 did not identify that the Vitamin D level had not been obtained in February 2026 as ordered. During interview, the DON confirmed the pharmacist failed to identify that the Vitamin D level was not obtained every six months as ordered on the March 2026 monthly Drug Regimen Review.
Failure to Obtain Ordered Vitamin D Lab
Penalty
Summary
The facility failed to ensure that Resident #14’s drug regimen was free from unnecessary drugs by not obtaining a Vitamin D level as ordered. Resident #14 was admitted on 07/02/2024 with diagnoses including cerebral palsy, anxiety, and vitamin deficiency. The care plan identified vitamin deficiency and directed staff to administer medications as ordered and draw labs as ordered by the physician. Physician orders included Ergocalciferol (Vitamin D2) 1.25 mg by mouth every Friday for vitamin deficiency and an order dated 08/08/2025 to obtain a Vitamin D level every six months. Review of the record showed no documented evidence that a Vitamin D level was obtained in February 2026 as ordered, and the DON confirmed during interview on 04/21/2026 at 12:00 p.m. that the lab had not been obtained.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure its medication error rate did not exceed 5% and was found to have a 7% medication error rate. During observation of a medication pass for Resident #4, S3LPN used a teaspoon to scoop a dose of Miralax, even though the April 2026 physician order specified Miralax 17 grams, 1 scoop. The manufacturer’s instructions reviewed by surveyors stated the bottle cap should be filled to the top of the white section to indicate the 17 gram dose. After the medication pass, review of the physician orders showed Resident #4 was also supposed to receive Senna 8.6 mg by mouth, but S3LPN did not administer it during the morning medication pass as prescribed. S3LPN later confirmed she gave only a teaspoon of Miralax and did not administer the Senna. S2DON was notified of the two medication errors, which resulted in a medication error rate of 7%.
Failure to Report Injury of Unknown Origin with Fracture to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin with serious bodily injury to the State Survey Agency as required by state law and the facility’s own Abuse Reporting and Investigation Policy and Procedure. The policy states that all reports of abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown source must be promptly reported to local, state, and federal agencies and thoroughly investigated, and that suspicious injuries of unknown origin, including fractures in cognitively impaired residents when not witnessed, must be reported. The facility’s policy further defines injuries of unknown origin as those not observed by any person, not explainable by the resident, and suspicious due to the extent or location of the injury. Record review showed that a resident with diagnoses including COPD, adult failure to thrive, repeated falls, generalized anxiety disorder, dementia with agitation, and delirium had severe cognitive impairment, with a BIMS score of 7, and required one-person assistance for standing and transfers. An incident report documented that this resident was found with bruising and swelling to the lower left leg in the evening, and an x-ray obtained the next day revealed acute mid and distal fractures of the tibia and fibula. The DON reported that the resident was unable to state the cause of the injury due to dementia and that the facility’s investigation could not determine a cause for the fracture, meeting the criteria for an injury of unknown origin with serious bodily injury. The Administrator, who was responsible for notifying the State Survey Agency, confirmed that the facility did not report this injury as required by the facility’s policy and state reporting requirements.
Failure to Notify Responsible Party of X-ray Results
Penalty
Summary
The facility failed to immediately notify the responsible party of a resident's x-ray results. The resident, who had diagnoses including Alzheimer's disease, psychotic disturbance, mood disturbance, anxiety, and a history of musculoskeletal conditions, was readmitted to the facility and required assistance with activities of daily living. The resident had moderate cognitive impairment, as indicated by a Brief Interview for Mental Status score of 11. On a specific date, the resident was observed resting in bed with a faint pinkish area on her right forearm. A review of the medical record showed that a nurse practitioner ordered an x-ray of the resident's right shoulder/arm, and the x-ray was performed and interpreted on the same day. The LPN signed and dated the report, but there was no documented evidence that the resident's responsible party was notified of the x-ray results. This lack of timely notification was confirmed by the Director of Nursing during an interview.
Failure to Assess Safety Device for a Resident
Penalty
Summary
The facility failed to accurately assess the effectiveness and necessity of safety devices for a resident. The facility's policy on safety and supervision requires documenting interventions and evaluating their effectiveness. However, the medical records for a resident with multiple diagnoses, including muscle weakness, dystonia, mood disorder, altered mental status, and schizophrenia, did not include an assessment of the raised edge mattress being used as a safety device. Observations on two consecutive days confirmed that the resident was lying on a mattress with raised edges, but the safety device assessment did not account for this. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed the omission in the assessment.
Failure to Provide Adequate Activities for Blind Resident
Penalty
Summary
The facility failed to provide an ongoing program to support a resident with blindness in their choice of activities. The resident, who had a diagnosis of blindness in both eyes, reported not receiving any activities and not being informed of when activities were going to take place. Despite being provided with a monthly activity calendar and attending some social events, the resident expressed dissatisfaction with the activities provided, rating his satisfaction level as a 2 out of 10. The Activity Director confirmed that the resident was not individually informed of upcoming activities.
Failure to Follow Bed Rail Protocols
Penalty
Summary
The facility failed to ensure proper procedures were followed for the use of bed rails for four residents. Specifically, the facility did not obtain a physician's order, informed consent from the residents or their representatives, or conduct an assessment for the risk of entrapment prior to the installation of bed rails. This deficiency was observed in residents with varying degrees of cognitive and physical impairments, including Parkinson's disease, Alzheimer's disease, and cerebrovascular conditions. Resident #30, who had intact cognition, was observed with loose bed rails, and there was no documentation of a physician's order, informed consent, or risk assessment. Similarly, Resident #23, with severe cognitive impairment, was found with bed rails raised without the necessary documentation or assessments. Resident #34, also severely impaired, and Resident #60, with moderate cognitive impairment, were both observed with bed rails installed without the required procedural steps being documented. The Director of Nursing confirmed the lack of documentation and procedural adherence for all four residents. The facility's policy on restraint devices requires an assessment of the resident's need, informed consent, and a physician's order, none of which were documented for these residents. This oversight indicates a systemic failure to comply with established protocols for bed rail use, potentially compromising resident safety.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications by not monitoring for bleeding in a resident receiving anticoagulant therapy. The medical records for the resident, who had a history of cerebral infarction, transient cerebral ischemic attack, atherosclerotic heart disease, old myocardial infarction, long-term use of anticoagulants, and chronic atrial fibrillation, showed an order for Eliquis and Aspirin. The care plan indicated a risk for bleeding due to anticoagulant therapy, with interventions to monitor for signs and symptoms of bleeding and notify the physician if any were observed. However, there was no documented evidence of monitoring for bleeding in the resident's medical record. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed the lack of documentation for monitoring bleeding or bruising when administering the anticoagulants.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a survey. Clean pots and pans were stored on a shelf that had old food particles, indicating improper cleaning and storage practices. Additionally, the ice machine was found to have a significant buildup of an unknown black substance on the inside lid and dust accumulation on the filters, both of which were confirmed by the Dietary Manager as needing cleaning. These conditions suggest a lack of regular maintenance and sanitation in the kitchen area. Further deficiencies were noted in the storage of food items and bottled water. In the walk-in freezer, boxes of beef patties and Churro Bites were left open and exposed to air, which the Dietary Manager acknowledged as improper sealing. Moreover, flats of bottled water were stored directly on the floor in the storage room, contrary to standard storage practices. These findings were reported to the facility's administrator, highlighting the need for improved food safety and storage protocols to ensure the well-being of the 84 residents receiving meal trays from the kitchen.
Sanitation Breach in Kitchen Due to Improper Storage of Personal Items
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, which is crucial for preventing the development and transmission of communicable diseases and infections. During an observation on February 24, 2025, a purse was found on a top shelf next to food preparation items, and a jacket was in direct contact with exposed parchment paper. Additionally, a storage room in the back of the kitchen contained personal belongings, including jackets and a purse, hanging next to a cart with several cans of soup. These observations indicate a lack of adherence to proper storage protocols for personal items in food preparation and storage areas. S9Dietary, who was present during the observations, confirmed that the purse belonged to her but was unaware of the jacket's owner. S8Dietary Manager acknowledged that kitchen staff were not supposed to store personal belongings in the kitchen and storage room due to the risk of cross-contamination. The Diet Type Report indicated that 84 residents received meal trays from the kitchen, highlighting the potential impact of these unsanitary practices. The facility's administrator was informed of these findings on February 26, 2025.
Unsafe Mechanical Equipment in Kitchen
Penalty
Summary
The facility failed to maintain all mechanical equipment in safe operating condition, as evidenced by a buildup of metal shavings on the can opener and a grease buildup inside the deep fryer. During an observation of the kitchen, it was noted that the commercial can opener had a significant accumulation of metal shavings beneath the blade. Additionally, the large gas fryer was observed to have a buildup of grease on its internal components. These observations were confirmed by the Dietary Manager, who was present at the time. The facility's Diet Type Report indicated that a total of 84 residents received meal trays from the kitchen, potentially exposing them to the risks associated with the equipment's condition. The Administrator was informed of these findings two days later.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident who was unable to activate his call light due to physical disabilities. The resident, who was admitted with a diagnosis of wedge compression fracture of the T11-T12 vertebra, demonstrated his inability to move his left arm and right fingers, which prevented him from pressing the call light button. During an interview, the resident confirmed his inability to activate the call light, and this was further verified by the Director of Nursing during a room visit with the surveyor.
Failure to Report Elopement Incident
Penalty
Summary
The facility failed to report an elopement incident involving a resident with severe cognitive impairment and a high risk for elopement. The resident, diagnosed with unspecified dementia and wandering behavior, was able to leave the facility without staff awareness. The incident occurred when a sitter, mistaking the resident for a visitor, opened an emergency exit door, allowing the resident to exit the building. The resident was later found walking outside the facility by an LPN, who, with the help of a neighbor, returned the resident to the facility without any observed injuries. The facility's policy required incidents of elopement to be reported to the State Survey Agency within 24 hours, but this was not done. The administrator confirmed that the incident was not reported in the Statewide Incident Management System (SIMS). The resident was assessed as high risk for elopement, and the incident highlighted a lapse in supervision and communication among staff, as the resident was able to leave the facility unnoticed until informed by the sitter.
Resident Elopement Due to Inadequate Supervision and Lack of Alert System
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident identified as high risk for wandering. The resident, diagnosed with unspecified dementia and behavioral disturbances, was assessed as having severe cognitive impairment and was noted to be independent with transfers. Despite being equipped with a wander guard bracelet, the resident was able to leave the facility without staff awareness due to a lapse in supervision. The incident occurred when a private sitter for another resident mistakenly allowed the resident to exit through an emergency door, believing the resident to be a visitor. The resident was observed walking outside the facility by a Licensed Practical Nurse (LPN) who was informed by the sitter. The LPN immediately pursued the resident and, with the assistance of a neighbor, returned the resident to the facility without injury. The resident was found to be in stable condition with no agitation or distress. Interviews with facility staff revealed that the exit door used by the resident did not have a code alert bracelet system to notify staff of the resident's proximity. This lack of an alert system contributed to the staff's unawareness of the resident's exit. The Director of Nursing and the Administrator confirmed the deficiency, acknowledging that the resident was able to elope without staff knowledge until the incident was reported by the sitter.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, specifically for two residents who were reviewed for unnecessary medications. For one resident, the facility did not adhere to the prescribed insulin sliding scale and blood pressure parameters. The resident had a history of type 2 diabetes mellitus, hypertension, and other significant health conditions. Despite having clear physician orders to hold Lisinopril if the diastolic blood pressure was below 75 and to hold insulin if the blood sugar was below 150, the nurses administered these medications multiple times without following the parameters. This oversight was confirmed through interviews with the LPNs and the Director of Nursing. Another resident, who also had a history of hypertension and other health issues, was affected by the facility's failure to follow prescribed blood pressure parameters. The resident's physician orders specified holding Metoprolol Tartrate if the pulse was below 60 or systolic blood pressure was below 110. However, the medication was administered several times despite the resident's vital signs being outside the specified parameters. This was confirmed through a review of the Medication Administration Records and interviews with the nursing staff. The surveyor's findings highlighted a pattern of non-compliance with medication administration protocols, as evidenced by the repeated failure to adhere to physician orders for both residents. The Director of Nursing acknowledged these deficiencies during the surveyor's review, and the facility's administrator was informed of the findings. The report underscores the importance of following physician orders to ensure the safety and well-being of residents in the facility.
Deficiency in Resident Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a resident who was unable to perform activities of daily living independently. The resident, who was readmitted with multiple diagnoses including type 2 diabetes mellitus with diabetic retinopathy, hemiplegia, hemiparesis, and blindness, required extensive assistance with personal hygiene. During an observation, it was noted that the resident had a thick buildup of black crust between the toes, areas of moisture with a sticky white coating, and an odor emanating from the left foot. Additionally, the resident had long, untrimmed nasal hairs. These findings were confirmed by a CNA and later by an LPN, who acknowledged the need for further attention to the resident's hygiene. The Director of Nursing was informed of the hygiene issues, including the crusty buildup and odor between the resident's toes and the untrimmed nasal hairs. The DON confirmed that the resident's feet should have been cleaned during baths and nasal hairs trimmed. The facility's failure to ensure the resident's personal hygiene needs were met was documented, highlighting a deficiency in the care provided to the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tallulah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vicksburg Convalescent Center | 17.9 mi | ★★★★★ | 0 | 0 |
| Heritage House Nursing Center | 18.7 mi | ★★★★★ | 7 | 0 |
| Deerfield Nursing And Rehabilitation Center | 18.8 mi | ★★★★★ | 4 | 1 |
| The Bluffs Rehabilitation And Healthcare Center | 19.8 mi | ★★★★★ | 4 | 1 |
| Shady Lawn Health And Rehabilitation | 19.8 mi | ★★★★★ | 4 | 0 |
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