Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legacy At Corsicana Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, COPD, lung cancer, and other chronic conditions had an unwitnessed fall and was found partly off the bed with no apparent injury. Although an initial assessment and one off-cycle neuro check were documented, several scheduled neuro checks were missed in the EMR. The DON, MD, Regional Compliance Nurse, and an LPN all acknowledged the missed assessments and stated that unwitnessed falls require neuro checks.
Failure to Report Abuse Allegation: A resident with severe cognitive impairment and multiple chronic conditions alleged that a staff member grabbed her wrist and pulled her to the floor, with discoloration noted on the wrist. Hospice staff notified the ADM and HR of the allegation, but the ADM stated she did not plan to report it to the state because she did not believe abuse occurred and was not aware of bruising. Facility leadership later confirmed the allegation was known, and policy required immediate reporting of abuse allegations.
Incomplete Comprehensive Care Plans: The facility failed to complete person-centered care plans for three residents by leaving key details blank or unspecified. One resident’s plan did not identify the cause of a communication problem or why tube feeding was needed; another resident’s plan omitted the allergy, pain goal, pain triggers, pain relief measures, and discharge reason; and a third resident’s plan did not state the cause of a swallowing problem, why tube feeding was required, or the residual amount for holding an enteral feeding. The residents had significant medical issues including dysphagia, stroke, CAD, HF, renal failure, fibromyalgia, and severe cognitive impairment.
Unsecured medication cart screen exposed resident information. A med aide was administering meds behind a privacy curtain while the medication cart remained unlocked and the laptop screen was visible to passersby, showing resident medication and medical information. The MA stated the screen should not be visible when she was not in direct line of sight, and the DON and ADM stated the cart and screen were expected to be secured so no patient information could be seen.
Unlocked Medication Cart Left Unattended: A med cart was observed parked in front of a resident room and left unlocked while the MA was behind a curtain with a resident. The cart screen showed unknown resident information, and a box of eye lubricating drops was on top of the cart. The MA stated the cart should be locked whenever she was not in direct line of sight, and the DON and ADM stated the cart and medications were expected to be locked away.
Failure to Provide Appropriate Alternate Meals: Two residents did not receive food that matched their needs and preferences. One resident with pancreatic CA, dental pain, and poor chewing ability was served a plain sandwich and chips despite requesting the alternate menu, while another resident with dementia, malnutrition, nausea, and documented food allergies/dislikes requested soup but was refused and instead had a sandwich and chips. Staff reported the microwave was broken, the alternate menu was not posted, and the dietary manager stated the resident should not have been denied soup.
Posted menu and meal tickets did not match the lunch actually served. Staff prepared and served a Mardi Gras-themed substituted meal, but the printed menu still listed BBQ chicken quarter, baked macaroni and cheese, green beans, a roll, apple cobbler, and iced tea. A resident said the meal tasted good and met his needs, but it was not what was listed on his ticket. The DM stated the substitution was planned by corporate office, but the electronic and posted menus were not updated.
A resident's care plan was not updated to reflect a recent left below-knee amputation, despite facility policy requiring revisions after significant changes. Interviews with staff revealed unawareness of the omission, which could have impacted care. The facility's policy mandates regular review and revision of care plans, but this was not adhered to in this case.
Missed Neuro Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure that neuro checks were completed after an unwitnessed fall for a resident with acute respiratory failure with hypoxia, COPD, hypertension, hyperlipidemia, lung cancer, and dementia. The resident’s admission MDS reflected a BIMS of 1, indicating severe cognitive impairment, and the care plan identified him as at risk for falls related to confusion, deconditioning, gait and balance problems, and incontinence. After being found half way off the bed with his torso on the floor and no apparent injury, he was assisted back to bed and the physician, RP, and DON were notified. The fall event note documented the resident as unwitnessed and discovered on the floor. The EMR showed that neuro assessments were not completed at the scheduled times of 7:30 am, 8:30 am, 10:30 am, and 12:30 pm after the fall, although an off-cycle neuro assessment was completed at 9:30 am. The facility’s EMR schedule for neuro checks was described as the initial assessment in the fall event note followed by checks every 15 minutes x4, every 30 minutes x2, every 1 hour x2, every 2 hours x2, and every 8 hours x8. During interviews, the DON stated that unwitnessed falls require neuro checks and that missed assessments could allow changes in condition to be missed. The MD stated that any unwitnessed fall or fall with head injury should have neuro checks completed. The Regional Compliance Nurse stated the assessments were to be completed in the EMR and that if an assessment stayed open it would not trigger the next one. Nurse A acknowledged that several neuro checks were missed, stated the morning was busy, and said she had been checking on the resident frequently but had not documented it in the EMR.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving Resident #2 was reported immediately to the state agency. Resident #2 was a [AGE] year-old female with diagnoses including heart disease, muscle wasting, high blood pressure, type 2 diabetes mellitus, hyperlipidemia, hearing loss, and enlarged heart. Her quarterly MDS reflected a BIMS score of 4, indicating severe cognitive impairment. She was discharged from the facility on 5/11/2026 and later reported to hospice staff that while she had been living at the facility, a big tall African American man who worked as either an aide or a nurse grabbed her left wrist and pulled her onto the floor, and that this had happened previously, though she could not provide dates. The hospice RN documented that Resident #2 had bruising or discoloration to the left wrist and that the family was aware and present during the allegations. On 5/14/2026, the hospice RN notified the facility’s HR and ADM in person of the abuse allegations. The RN stated the ADM said she was not planning to report the allegations to the state. The ADM later stated she did not report the allegation because she did not feel the resident had been abused and she was not aware of any injuries or bruising, although she acknowledged it was her responsibility to report all allegations of abuse or neglect. The FM stated he was aware of the allegations and that the ADM called him on 5/14/2026 to ask about them. He said he did not see abuse, did not notice bruising on the left wrist, and believed the resident’s discoloration may have been related to age-related skin changes. The ADO stated he was not aware of the allegation until the day of interview and confirmed that the ADM is responsible for reporting all allegations of abuse or neglect per provider letter. The facility policy stated that all allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, or injury of unknown source must be reported to the administrator, and that the administrator or designee must report allegations involving abuse within 2 hours or other allegations within 24 hours.
Incomplete Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 3 of 5 residents reviewed. The deficiency involved incomplete care plan entries for Resident #1, Resident #23, and Resident #60, where key medical and nursing needs were not fully identified in the care plan documentation. The facility’s policy stated that comprehensive care plans must include measurable objectives and timeframes to meet each resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. For Resident #1, the comprehensive MDS reflected diagnoses including GERD, septicemia, seizure disorder, muscle wasting and atrophy, and dysphagia. The resident had clear speech, could make himself understood, could understand others, and had a BIMS score of 04 indicating severe cognitive impairment. His comprehensive care plan listed a focus of “The resident has a communication problem r/t” and “The resident requires tube feeding r/t” but did not state what the communication problem was related to or why he required tube feeding. For Resident #23, the MDS reflected diagnoses including CAD, heart failure, renal failure, diabetes, cirrhosis of the liver, fibromyalgia, and chest pain. She had a BIMS score of 15 and the pain assessment interview ended after she reported no pain in the last 5 days. Her care plan included a focus of “Allergic to (specify),” a pain goal with a blank target level, interventions for what aggravated and relieved pain with blanks, and a discharge focus stating discharge was not feasible with a blank reason. Her physician orders listed allergies to iodine, lidocaine, sulfa antibiotics, and tape, and pain-related orders included acetaminophen, diclofenac gel, pregabalin, and tramadol. For Resident #60, the MDS reflected diagnoses including stroke, anemia, hypertension, and pneumonia. He had a BIMS score of 02 indicating severe cognitive impairment, was coded as receiving tube feeding upon admission and while a resident, and received 51% or more of total calories by tube feeding. His care plan listed “The resident has a swallowing problem r/t” and “The resident requires tube feeding r/t” without stating the cause of the swallowing problem or why tube feeding was needed, and the intervention for residual checks stated “Hold feed if greater than (X) cc aspirate,” leaving the amount blank. His physician orders included NPO status, enteral feeding, head-of-bed elevation 30-45 degrees, and aspiration precautions.
Unsecured medication cart screen exposed resident information
Penalty
Summary
The facility failed to ensure the privacy of an unknown resident by not locking the laptop screen on the medication cart, allowing resident medication and medical information to be visible to someone walking by. During an observation on 02/18/2026 at 9:17 AM, a medication cart was parked in front of a resident room and left unlocked while MA A was behind a privacy curtain administering medication. The computer screen on the cart was visible and displayed unknown residents' medication and medical information, and MA A could not see the medication cart from where she was standing behind the curtain. During an interview, MA A stated that when she stepped away from the medication cart, the screen should not be visible and that she had been trained to lock the computer screen when it was not in direct line of eyesight or in use. She also stated she had been checked off on medication pass yearly by the pharmacist and as needed by the DON. The DON stated the expectation was that the medication aide should close the computer screen so no resident information could be seen, and the ADM stated the cart should be locked and the screen positioned so no patient information was visible when not in use. The facility policy titled RESIDENT RIGHTS stated that the resident has a right to personal privacy and confidentiality of personal and medical records.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and were inaccessible to unauthorized staff, visitors, and residents for 1 of 2 medication carts reviewed. During an observation on 02/18/2026 at 9:17 AM, Med Cart #1 was parked in front of room [ROOM NUMBER] and was unlocked while MA A was behind a private curtain with a resident. The medication cart screen was visible with unknown resident information, and a box of eye lubricating drops was on top of the cart. Other unknown residents in wheelchairs and their family members were present in the hallway. During interview, MA A stated she could not see the medication cart from where she was and said that whenever she stepped away from the cart, all medications and the cart should be locked and secured. She stated she had been trained to lock the cart when it was not in direct line of sight or in use. The DON stated the expectation was that when the medication aide was passing pills, all medications were put away and the cart locked. The ADM also stated the cart should be locked and all medications locked away. Facility policy titled Medication Storage in the Facility stated medications and biologicals are to be stored safely, securely, and properly, and that the medication supply is accessible only to authorized personnel.
Failure to Provide Appropriate Alternate Meals
Penalty
Summary
The facility failed to ensure that residents received food that accommodated their allergies, intolerances, and preferences for 2 residents reviewed for food and nutritional services. One resident had diagnoses including pancreatic cancer, HTN, T2DM, hypercholesterolemia, and recurrent major depressive disorder, with a BIMS score of 13 and documented oral/dental problems including broken or loose teeth, inflamed or bleeding gums, and mouth or facial pain. Progress notes also reflected poor appetite, refusal of lunch and supper, and treatment with amoxicillin for a dental infection. During lunch observation, this resident was served a plain meat and cheese sandwich cut in half with crumbled potato chips. The resident stated she was not really satisfied with the meal and reported that she had been unable to bite or chew because of dental problems, mouth, gum, and tooth pain. She said she had recently seen a dentist, was being treated for an infection, and was missing most of her teeth, which contributed to her inability to chew the food served. Her meal ticket reflected dislikes including rice, raw celery, raw apples, raw apricots, lettuce, salads, and raisins, and special notes of no spicy food and no chocolate. The second resident had diagnoses including unspecified dementia, protein calorie malnutrition, and hyperlipidemia, with a BIMS score of 15 and no nutritional approaches documented. Progress notes showed nausea and dry heaving, and the resident told the surveyor she had been throwing up and had an upset stomach. She requested a bowl of soup instead of the alternate meal, which was a meat and cheese sandwich with potato chips, but staff refused. Observation showed she was sitting alone near a dining table and not eating from the served plate, and her printed meal ticket listed dislikes and allergies including fish/tuna, tomato products, tomatoes, juice, and apple juice, along with a note that she did not eat beef or pork all the time. The dining room had no alternate menu posting, and staff stated the microwave was broken and that soup could not be heated, while the dietary manager stated staff should not have refused the resident’s request for soup.
Posted Menu and Meal Tickets Did Not Match Served Lunch
Penalty
Summary
The facility failed to update and follow the posted lunch menu for Tuesday, 2/17/2026, and failed to ensure the substituted meal was reflected on the printed menu and residents’ meal tickets. During observation in the kitchen at 11:43 AM, staff were preparing white rice, a variety of combined meats with vegetables, chopped chicken and sausage, and individual servings of ribs without apparent sauce. Staff identified the meal as jambalaya being served in celebration of Mardi Gras. At 12:10 PM, residents in the facility’s only dining room were observed being served a combination of white rice, vegetables, and meat, along with a cupcake, tea, and a roll. Resident #41 stated the meal tasted good and met his needs and preferences, but said it was not what was listed on his meal ticket or what he expected, since he was not served baked macaroni and cheese or apple cobbler. Observation of residents eating in the dining room showed they consumed most, if not all, of the meal without complaint or dissatisfaction expressed. Record review showed the residents’ individually printed meal tickets did not match the meal served. The meal tickets listed BBQ chicken quarter, baked macaroni and cheese, homestyle green beans, honey kissed roll, apple cobbler, and iced tea. The posted printed weekly menu also listed BBQ chicken quarter, baked macaroni and cheese, homestyle green beans, honey kissed roll, apple cobbler, and iced tea, and no changes were observed on the posted menu. The DM stated the meal was a substitution initiated by corporate office for Mardi Gras, that she noted the substitution in her own records, but did not electronically make the menu changes because she did not know how and overlooked updating the posted printed menu. The ADM stated the DS was responsible for updating electronic and printed menus when modifications occurred, and the facility policy stated the menu could be modified to meet resident preferences and should reflect the religious, cultural, and ethnic needs of the resident population.
Failure to Update Care Plan After Resident's Amputation
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan for a resident who had undergone a left below-knee amputation was not updated to reflect this significant change in the resident's condition. The care plan, dated several months prior to the amputation, did not include the amputation, which could have affected the resident's activities of daily living (ADLs) and the care provided by the staff. Interviews with facility staff, including the MDS nurse, DON, and ADM, revealed that they were unaware that the resident's care plan had not been updated to include the amputation. The MDS nurse, who was responsible for completing and revising care plans, acknowledged that the amputation should have been included in the care plan and that its omission could have impacted the staff's ability to provide appropriate care. The DON and ADM also confirmed that the care plan should have been updated to reflect the resident's current status and that the omission could have led to confusion among staff regarding the resident's care needs. The facility's policy on comprehensive care plans requires that they be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The policy also emphasizes the importance of including measurable objectives and timeframes to meet the resident's needs as identified in the comprehensive assessment. Despite these guidelines, the care plan for the resident in question was not updated to reflect the significant change in the resident's condition, highlighting a failure in the facility's care planning process.
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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 Corsicana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Village At Heritage Oaks | 0.3 mi | ★★★★★ | 1 | 0 |
| Twilight Home | 0.4 mi | ★★★★★ | 5 | 0 |
| Epic Nursing & Rehabilitation | 0.4 mi | ★★★★★ | 8 | 0 |
| Meadows Of Corsicana, Llc | 0.6 mi | ★★★★★ | 0 | 0 |
| Kerens Care Center | 16.5 mi | ★★★★★ | 1 | 1 |
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