Legacy Manor Nursing and Rehabilitation Center
Legacy Manor Nursing and Rehabilitation Center is a for profit - limited liability company facility in Greenville, MS with 60 certified beds and a 4-star overall CMS rating. The inspection file holds 18 deficiency records. Total penalties: $27K.
1935 North Theobold Extension, Greenville, MS 38704
Phone: 6623344501
Overall CMS Rating
vs 3.0 national avg
The verdict
Legacy Manor Nursing and Rehabilitation Center holds a 4-star CMS overall rating — well above the 3.0-star national average, with nurse staffing below the national norm. 3 inspection findings reached the actual-harm or immediate-jeopardy level.
- 4 / 5
- CMS overall rating (nat'l avg 3.0)
- 3.53
- Nursing hrs/resident-day (nat'l 3.89)
- 18
- Inspection findings on file · 3 serious
- $27K
- Federal penalties (2)
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating. Read the components below — they often tell a sharper story than the headline.
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 255292
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 60
- Residents
- 49
- In Hospital
- No
- County
- Washington
- Last Inspection
- Jun 13, 2024
Staffing Data
- RN Hours
- 0.50 (nat'l avg: 0.68)
- LPN Hours
- 1.07
- CNA Hours
- 1.96
- Total Nursing Hours
- 3.53 (nat'l avg: 3.89)
- PT Hours
- 0.01
- Nursing Turnover
- 35.6%
- RN Turnover
- 33.3%
What the CMS Record Reveals About Legacy Manor Nursing and Rehabilitation Center
Legacy Manor Nursing and Rehabilitation Center operates 60 certified beds in Greenville, MS with approximately 49 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (4★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 18 deficiency records from recent surveys, of which 3 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $27K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.53 total nursing hours per resident day (national average 3.89), with RN coverage at 0.50 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, Legacy Manor Nursing and Rehabilitation Center falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 35.6%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (18 most recent)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 27, 2024
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 6, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 6, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 12, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 12, 2024
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Category: Resident Rights Deficiencies
Corrected: Jul 12, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jul 28, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 10, 2023
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Mar 10, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 10, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 10, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 10, 2023
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 23, 2019
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 23, 2019
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 23, 2019
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 23, 2019
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 23, 2019
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Sep 23, 2019
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 4.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 3.3% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 98.7% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 1.4% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 11.7% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 100.0% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 8.5% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 6.9% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 0.0% | Yes |
Penalty History 2 penalties totaling $27K
| Date | Type | Amount |
|---|---|---|
| Jan 14, 2025 | Fine | $17K |
| Sep 9, 2024 | Fine | $10K |
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Understanding Nursing Home Data
Frequently Asked Questions
What is the overall CMS rating for Legacy Manor Nursing and Rehabilitation Center?
What are the staffing levels at Legacy Manor Nursing and Rehabilitation Center?
How many beds does Legacy Manor Nursing and Rehabilitation Center have?
Does Legacy Manor Nursing and Rehabilitation Center have any deficiencies on record?
Has Legacy Manor Nursing and Rehabilitation Center received any fines or penalties?
Who owns Legacy Manor Nursing and Rehabilitation Center?
When was Legacy Manor Nursing and Rehabilitation Center last inspected?
What quality measures are tracked for Legacy Manor Nursing and Rehabilitation Center?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.