Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Improper thermometer calibration and food storage practices were observed in the kitchen. A cook calibrated the thermometer to 40 degrees instead of the required 32 degrees, even though staff had been trained on proper calibration. Surveyors also found opened and refrigerated food items that were not labeled or dated, along with sandwiches left unattended on a prep table with no date, and the DM could not state how long they had been there.
The facility failed to accurately report PBJ staffing when RN and LPN administrative nursing hours were entered under incorrect job titles. The MDS nurse, medical records nurse, and staff development nurse stated they worked primarily in administrative roles and usually on weekdays, but PBJ showed limited contract hours recorded for administrative job titles and the Administrator confirmed the direct care staffing data was not accurately reported.
A resident in a long-term care facility was physically abused by a CNA, who punched the resident multiple times and flipped his wheelchair, leaving him unattended on the floor. The resident, who was severely cognitively impaired, sustained injuries and was unable to recall the incident. The facility's security footage captured the abuse, leading to the CNA's termination and legal action by the Attorney General's office.
A resident with a Full Code status did not receive CPR or emergency services when found unresponsive by an LPN, despite the care plan and physician's order indicating the need for CPR. The LPN notified the coroner and family of the resident's death without initiating CPR, leading to an Immediate Jeopardy situation.
A resident with a Full Code status was found unresponsive with no respirations or pulse, but CPR was not initiated by an LPN. The LPN, who was aware of the resident's code status, did not perform CPR or call emergency services, instead notifying the coroner and family. The facility's policy requires CPR unless a DNR order is present, which was not the case. The resident was pronounced deceased without CPR being attempted.
A resident reported that the toilet in their bathroom was loose and moved when used. Observation confirmed that three-fourths of the caulking around the toilet base was missing. The facility's Maintenance and Repair Log did not document this issue. The Maintenance Man was unaware of the problem and acknowledged the potential danger, while the Administrator agreed that staff should have reported the loose toilet.
The facility failed to implement ADL care plans for two residents requiring nail care and facial grooming. One resident had long fingernails and patchy facial hair, while another had jagged nails with a brown substance and unshaven facial hair. Staff confirmed the care plans were not followed, as these grooming needs were unmet.
The facility failed to provide adequate personal hygiene care for two residents, resulting in long, jagged fingernails with a brown substance underneath and unshaven facial hair. One resident had an active order for weekly nail care, but there was no documentation of care provided. Staff interviews revealed uncertainty about when the residents last received nail care or shaving, despite acknowledging the need for it. The residents were admitted with diagnoses including primary open-angle glaucoma, lack of coordination, cognitive communication deficit, and weakness.
Improper Thermometer Calibration and Food Storage
Penalty
Summary
The facility failed to ensure accurate food temperatures because the cook calibrated the food thermometer to 40 degrees instead of 32 degrees, despite the facility policy requiring thermometers to be calibrated before each meal using the ice point method. During observation, the cook stated she had been trained to calibrate the thermometer to 35 or 38 degrees and confirmed she chose to calibrate it to 40 degrees on her own each day. The Dietary Manager stated staff had been educated on calibrating the thermometer to 32 degrees, and the Administrator stated the cook was responsible for making sure the thermometer was calibrated correctly so food temperatures were registered correctly. The facility also failed to store food in accordance with professional standards during kitchen observations. In one refrigerator, surveyors observed an opened carton of thickened apple juice with a best-if-used-by date, a beverage pitcher with no label or date containing an unidentified liquid, and other refrigerated items including milk and yogurt that were not properly dated. A tray of cold cut and cheese sandwiches was also observed sitting unattended on a food prep table with no date, and the Dietary Manager could not say how long they had been there. The Dietary Manager acknowledged responsibility for monitoring kitchen food labeling, dating, storage, quality, and discarding expired foods, and the Administrator stated the kitchen staff were responsible for monitoring expiration dates, proper storage, and proper labeling.
Inaccurate PBJ Reporting of Administrative Nursing Hours
Penalty
Summary
The facility failed to ensure the accuracy of PBJ data submitted to CMS when nurses with administrative nursing duties were not recorded in the correct job title for three months reviewed in FY first quarter 2026. The PBJ Staffing Data Report for FY Quarter 1 2026 showed the facility triggered for excessively low weekend staffing during the quarter. Review of the 1703D Job Title Report showed contract hours recorded under Job Title 6 - RN with Administrative Duties on 10/7/26, 11/5/26, 11/6/26, 12/15/26, and 12/16/26, with no other days recorded for that job title. The report also showed contract hours recorded under Job Title 8 - LPN/LVN with Administrative Duties on 10/7/26, 10/22/26, 10/24/26, 10/25/26, 10/26/26, and 11/2/26. During interviews, the MDS nurse stated she did not work on the floor providing direct resident care during the first quarter of 2026 and provided administrative duties only, usually Monday through Friday. The medical records nurse stated she worked mostly in an administrative role and did not routinely provide direct resident care, and the staff development nurse stated she worked primarily in an administrative capacity during the week and only on several occasions provided direct care. The Administrator confirmed the facility did not accurately report direct care staffing during weekdays and stated corporate staff had entered the job title codes incorrectly because the hours for nurses with administrative duties did not reflect their actual hours worked.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in a serious incident involving a Certified Nursing Assistant (CNA) and a resident. The CNA physically assaulted the resident by punching him in the head, face, and chest multiple times and then flipping his wheelchair, causing the resident to fall onto the hallway floor. This incident was captured on the facility's security camera, which showed the CNA hitting the resident with a closed fist approximately ten times and then leaving him unattended on the floor for over 30 minutes. The resident involved in the incident was severely cognitively impaired, with a history of alcohol abuse, dementia with behaviors, and cognitive communication deficit. At the time of the incident, the resident was unable to recall the details of the altercation or how he sustained injuries, which included broken blood vessels in his right eye. The facility's investigation revealed that the CNA did not attempt to seek help or report the incident, and instead, she continued to work her shifts without mentioning the altercation to any staff members. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Practical Nurses (LPNs), confirmed that the CNA's actions were abusive and neglectful. The facility's security footage contradicted the CNA's claim that the resident had attacked her first. The DON and LPNs were shocked by the abuse they witnessed on the video, which led to the termination of the CNA. The incident was reported to the Attorney General's office, and charges were pursued against the CNA for felony abuse and neglect.
Failure to Implement CPR for Full Code Resident
Penalty
Summary
The facility failed to implement care plan interventions related to Cardiopulmonary Resuscitation (CPR) for a resident who was found to have no respirations and no pulse. The resident, who was a Full Code status, did not receive CPR or emergency services when discovered unresponsive by a Licensed Practical Nurse (LPN). The LPN, upon finding the resident without vital signs, notified the coroner, family, Administrator, and Nurse Practitioner of the resident's death without initiating CPR or calling emergency services. The resident's care plan clearly indicated a Full Code status, which required CPR to be performed in the event of an emergency. The resident's medical record and a physician's telephone order confirmed the Full Code status, emphasizing the need for CPR. Despite this, the LPN did not follow the care plan or the facility's policy, resulting in the resident not receiving the necessary life-saving measures. The facility's failure to adhere to the care plan and initiate CPR for the Full Code resident was identified as an Immediate Jeopardy situation. The deficiency was confirmed through interviews and record reviews, highlighting the lack of action taken by the LPN despite being aware of the resident's code status and the facility's policy requirements.
Removal Plan
- In-service training for all staff on Cardiopulmonary Resuscitation Policy, Change in Resident Medical Status, Emergency Care of Residents, Care Plan Process, Advance Directives, physician orders, Resident Rights, Resident Abuse/Neglect and Reporting.
- Code drills for all Registered Nurses and Licensed Practical Nurses, with participation required before providing direct patient care.
- Audit of all active resident's medical record charts to ensure proper code status identification.
- Audit of all active residents' plan of care to ensure proper code status identification.
- Monitoring systems to sustain compliance, including verification of licensed staff Cardiopulmonary Resuscitation certification status upon hire, monitoring of active resident medical records and plan of care for correct code status.
- Monitoring of cardiopulmonary resuscitation code drills on all three shifts.
- Crash cart inventory checks.
- Follow-up Quality Assurance Meetings.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to initiate Cardiopulmonary Resuscitation (CPR) and provide emergency services to a resident who was found to have no respirations and no pulse. The resident, who had a Full Code status, was discovered unresponsive by a Licensed Practical Nurse (LPN) who did not perform CPR or call emergency services. Instead, the LPN notified the coroner, the family, the Administrator, and the Nurse Practitioner of the resident's death. The resident was pronounced deceased at the facility. The facility's Cardiac Resuscitation Policy mandates that basic life support, including CPR, should be provided when a resident requires such emergency care, unless a valid Do Not Resuscitate (DNR) order is in place or obvious clinical signs of death are present. In this case, the resident's medical record indicated a Full Code status, meaning CPR should have been initiated. However, the LPN did not perform CPR, citing the resident's lack of vital signs as the reason. Interviews with facility staff revealed that the LPN was instructed by the Staff Development Coordinator to initiate CPR but failed to do so, believing the resident was already deceased. The Deputy County Coroner noted that the resident did not exhibit rigor mortis or dependent lividity, which are signs of death, at the time of her assessment. The facility Administrator confirmed that CPR should have been initiated, but it was not performed, leading to the determination of Immediate Jeopardy and Substandard Quality of Care.
Removal Plan
- In-service training was initiated by Staff Development Nurse #1 and Assessment Nurse #1 to include all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department on the following: (a) Cardiopulmonary Resuscitation Policy, (b) Change in Resident Medical Status, (c) Emergency Care of Residents, (d) Care Plan Process, (e) Advance Directives, physician orders (f) Resident Rights, (g) Resident Abuse/Neglect and Reporting.
- Cardiopulmonary Resuscitation (CPR) Code Drills were initiated by the facility Staff Development Nurse #1 and the facility Assessment Nurse #1 for all Registered Nurses and Licensed Practical Nurses. Registered Nurses and Licensed Practical Nurses will not be allowed to provide direct patient care until participation in a code drill has been conducted. Code drill exercises will be performed until all Registered Nurses and Licensed Practical Nurses have participated in at least one exercise, and then code drills will continue as outlined below.
- All active resident's medical record charts were audited by the facility Staff Development Nurse #1, and Assessment Nurse #1 to ensure proper code status identification. The results of this audit showed one discrepancy found and was immediately corrected.
- All active residents plan of care were audited by the facility Assessment Nurse #1 and the Staff Development Nurse #1 to ensure proper code status identification. The audit results showed no issues found.
- Monitoring systems were put in place to sustain compliance. (a) Verify licensed staff Cardiopulmonary Resuscitation certification status upon hire and by the Director of Nursing. (b) All active resident medical records and plan of care will be monitored for the correct code status. (c) the facility began monitoring cardiopulmonary resuscitation code drills on all three shifts, then per facility protocol thereafter (rotating shifts) (d) the facility began crash cart inventory checks.
- The facility Administration will have a follow up Quality Assurance Meeting.
Loose Toilet Poses Safety Risk
Penalty
Summary
The facility failed to maintain a safe environment for a resident when a toilet in the resident's bathroom was found to be loose. During an interview and observation, the resident reported that the toilet moved when he sat on it. Further observation revealed that three-fourths of the caulking around the base of the toilet was missing. A review of the facility's Maintenance and Repair Log for June 2024 showed no entries reporting the condition of the toilet. The Maintenance Man confirmed the missing caulking and the loose condition of the toilet, stating he was unaware of the issue and acknowledged the potential danger of the resident falling and getting hurt. The Administrator agreed that staff should have reported the loose toilet and recognized the risk of injury to the resident.
Failure to Implement ADL Care Plans for Nail and Facial Grooming
Penalty
Summary
The facility failed to implement an Activities of Daily Living (ADL) care plan for two residents who required nail care and facial grooming. Resident #21's comprehensive care plan indicated a need for assistance with ADLs, including bathing, but observations revealed that his fingernails were one-half inch long past the tip of his fingers, and he had patchy facial hair one inch long. During interviews, Resident #21 expressed a desire for his nails to be cut and his face shaved, but was unsure of when these tasks were last performed. A Licensed Practical Nurse (LPN) confirmed the resident's nails and facial hair were long and needed attention, but was also unsure of when these grooming tasks were last completed. Similarly, Resident #34's care plan indicated a dependency on staff for bathing, which includes nail care and shaving. Observations showed that Resident #34 had long, jagged fingernails with a brown substance underneath and facial hair approximately half an inch long. The Director of Nursing (DON) confirmed the need for nail cleaning and trimming. The Minimum Data Set (MDS) nurse, responsible for developing care plans, acknowledged that the care plans were not being followed for these residents, as their nails were not clean and trimmed, and they were not shaven as required.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care for two residents, resulting in long, jagged fingernails with a brown substance underneath and unshaven facial hair. Resident #21 was observed with fingernails extending half an inch past his fingertips and patchy facial hair one inch long. Despite having an active order for weekly nail care, there was no documentation of nail care or shaving for Resident #21 during the specified period. Interviews with staff revealed uncertainty about when the resident last received nail care or shaving, despite acknowledging the need for it. Resident #21 was admitted with diagnoses including primary open-angle glaucoma and lack of coordination. Resident #34 was observed with fingernails half an inch long, jagged, and with a brown substance underneath, along with facial hair half an inch long. The resident was supposed to be shaved on shower days, but this was not done. Staff interviews confirmed the responsibility of CNAs for nail care and shaving for non-diabetic residents, yet Resident #34's nails and facial hair were neglected. The Director of Nurses and a Registered Nurse confirmed the resident's nails were long and dirty, and the RN had to address the issue when it was brought to her attention. Resident #34 was admitted with diagnoses including cognitive communication deficit and weakness.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Greenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Heights Healthcare Center | 0.9 mi | ★★★★★ | 9 | 0 |
| Ms Care Center Of Greenville | 0.9 mi | ★★★★★ | 0 | 0 |
| Arbor Walk Healthcare Center | 1.2 mi | ★★★★★ | 2 | 0 |
| Washington Care Center | 1.9 mi | ★★★★★ | 6 | 0 |
| Lake Village Rehabilitation And Care Center | 15.4 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.