Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Legacies Nursing And Rehabilitation during CMS and state inspections, most recent first.
Dish machine sanitation failed because the kitchen dishwasher repeatedly did not reach the required 120°F wash temperature. The Dietary Mgr observed the machine running below temp, the temp log showed multiple readings under 120°F, and the Dietary Mgr believed it was acceptable to run the machine close to 120°F as long as the chemical test strips were within range. Facility policy and the manufacturer instructions both required the wash cycle to reach 120°F.
A resident with dementia, severe cognitive impairment, and total toileting dependence was exposed during incontinent care when a CNA and a new nurse aide left the door open and pulled back the privacy curtain while the resident was unclothed from the waist down. The open doorway and pulled-back curtain left the resident potentially visible to the hallway, and staff acknowledged that privacy and dignity were not maintained.
Failure to Follow Contact Precautions: A resident with diabetes, impaired cognition, and incontinence had contact isolation for a UTI, with a sign posted on the door requiring gown and gloves before entry. An MA entered the room, sat on the resident’s bed, and assisted with a meal without PPE. The LVN, DON, and Administrator confirmed the contact precaution process and PPE requirements, and the MA stated she overlooked the sign and should have worn PPE.
A facility failed to maintain a safe environment for two residents by not properly handling mechanical lift slings and not following care plans for resident transfers. One resident was transferred using a frayed sling, while another was manually lifted by a nurse aide who did not check the care plan, which required two-person assistance. Staff interviews revealed a lack of awareness and adherence to guidelines, contributing to the deficiencies.
Dish Machine Failed to Reach Required Sanitizing Temperature
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen because the dish machine was not maintained at the manufacturer-required wash temperature of 120 degrees Fahrenheit during the wash cycle. During an initial kitchen observation, the Dietary Manager was seen running the dishwasher and the temperature did not go above 110 degrees during testing. She stated it had been like that and that the facility had the same issues the prior year. The temperature log posted next to the dishwasher showed multiple temperatures below 120 degrees Fahrenheit, and the machine label stated that the water temperature minimum was 120 degrees Fahrenheit. Chemical test strips were tested at 200 ppm, which was within guidelines. Additional observations showed the dish machine repeatedly failing to reach the required temperature. A Maintenance man ran the machine four times before the temperature reached 120.4 degrees, and on another observation the Dietary Manager had to check the machine three times before it reached 120 degrees. Record review of the March 2026 Dish Machine Temperature & Chemical Log showed repeated below-minimum temperatures throughout the month, including breakfast, lunch, and dinner readings ranging from 112 to 118 degrees. The Dietary Manager stated she believed it was acceptable to run the dishwasher at a lower temperature as long as it was close to 120 degrees and the chemicals tested correctly, and she believed the combination of chemicals and near-120 temperature would sanitize the dishes. The facility policy and manufacturer instructions both indicated the low-temperature dish machine wash cycle was supposed to reach 120 degrees Fahrenheit.
Failure to Maintain Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure full visual privacy during incontinent care for Resident #73. Resident #73 was an elderly female with diagnoses including dementia, anxiety disorder, and Alzheimer's disease. Her annual MDS indicated a BIMS score of 04, showing severe cognitive impairment, and that she was incontinent of urine and bowel and required total assistance with toileting. Her care plan identified an ADL function disorder and directed staff to assist with ADLs as needed. During an observation of incontinent care, Resident #73 was being prepared for care by CNA A with the privacy curtain pulled around her, and she was unclothed from the waist down with her buttocks exposed. NA B knocked, asked to enter, left the door open, and drew back the curtain to speak with CNA A, standing at the open doorway while the curtain remained pulled back and the resident was potentially exposed to the hallway as staff walked by. This occurred again during a later observation and interview, when NA B again left the door open and pulled back the curtain while speaking with CNA A. CNA A stated the door should have been shut because the open door and pulled-back curtain exposed Resident #73 to the hallway and any passersby, and both CNA A and NA B acknowledged that privacy and dignity were not maintained.
Failure to Follow Contact Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents and 1 of 7 staff reviewed for infection control. The deficiency involved a resident with diabetes, moderately impaired cognition with a BIMS score of 09, dependence on staff for all ADLs, and incontinence of bowel and bladder. Her care plan identified a history of recurrent UTIs and required contact precautions with PPE worn before entering the room. The resident had an order for contact precautions for a UTI, and a sign was posted on her door indicating contact isolation and the need for gloves and gown before entry. During an observation, MA-C was in the resident’s room sitting on the resident’s bed and assisting with a meal without wearing PPE. The LVN stated that the urine culture had come back positive that morning and contact isolation had been initiated, and that staff and visitors were made aware through the sign on the door. She stated that PPE of gloves and gown should be applied before entering the room and removed before leaving it. During interview, MA-C said that when a resident was in contact isolation, a gown and gloves should be put on before entering the room, and that she had overlooked the sign because the order had come in that morning. She also said she should have had PPE on and should not have sat on the resident’s bed to prevent cross contamination. The DON stated she was responsible for the infection control program and that staff were to put on a gown and gloves before entering the room, remove them and wash hands before leaving, and that not following the contact isolation process could cause infections to spread. The Administrator stated that staff should recognize the isolation sign and follow the guidelines set for that isolation, and that the facility’s infection control policy should always be followed.
Deficiencies in Sling Maintenance and Resident Transfer Procedures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents. For one resident, the facility did not develop and implement a policy to properly handle mechanical lift slings. Observations revealed that the sling used for this resident was frayed, with faded straps and illegible care tags, indicating wear and potential compromise. Staff interviews indicated a lack of awareness regarding the manufacturer's guidelines for sling maintenance, which require slings with signs of wear or improper laundering to be removed from service. The Director of Nursing (DON) acknowledged the risk of injury if a sling failed during a transfer. Another resident was improperly transferred by a nurse aide who did not follow the care plan, which required assistance from two staff members for transfers. The nurse aide manually lifted the resident without using a gait belt, despite the resident's inability to bear weight. The nurse aide admitted to not checking the care plan Kardex for the resident's required level of care. Interviews with the charge nurse and MDS Coordinator confirmed that the resident's care plan had been updated to require two-person assistance, and staff were expected to check care plans daily for any changes. The facility's policies and training were not effectively implemented, as evidenced by the improper handling of lift slings and failure to follow care plans for resident transfers. The DON and Administrator acknowledged the deficiencies and the potential risk of injury to residents if proper procedures were not followed. The facility's failure to adhere to established guidelines and ensure staff competency in these areas contributed to the identified deficiencies.
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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 Hemphill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hemphill Care Center | 1.7 mi | ★★★★★ | 4 | 0 |
| Avir At San Augustine | 19.8 mi | ★★★★★ | 4 | 0 |
| Stonecreek Nursing & Rehabilitation | 21.1 mi | ★★★★★ | 6 | 0 |
| Colonial Pines Healthcare Center | 22 mi | ★★★★★ | 9 | 0 |
| Toledo Retirement And Rehabilitation Center | 23.6 mi | — | 0 | 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.