LEGACY MANOR NURSING AND REHABILITATION CENTER
1935 NORTH THEOBOLD EXTENSION, GREENVILLE, MS 38704
Below the repealed 0.55 hr RN benchmark — average inspection record.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
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0.50 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
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Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
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Total
18
Outstanding
0
Actual harm or worse (G–L)
3
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: ★★★★★ (5/5)
Staffing: ★★★★☆ (4/5)
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NursingHomeGrade Score
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64/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
3 immediate jeopardy issues found among 18 total deficiencies. 18 corrected.
Most recent inspection (June 13, 2024)
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 12, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected July 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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected July 12, 2024
Inspection cycle 2 (January 14, 2025)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Past Non-Compliance, corrected December 27, 2024
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 10, 2023
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Quality of Life and Care Deficiencies — Past Non-Compliance, corrected September 6, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 10, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 10, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 10, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Past Non-Compliance, corrected September 6, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 10, 2023
Inspection cycle 3 (June 29, 2023)
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 23, 2019
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 23, 2019
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 23, 2019
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 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.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 23, 2019
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 23, 2019
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