Map showing the location of LEGACY NURSING AND REHABILITATION OF WINNSBORO in WINNSBORO, Louisiana
804 POLK STREET, WINNSBORO, LA, 71295

Overall Score

CMS Five-Star Quality Rating
2/5Below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • LouisianaAbove only 34% of peers264 rated homes · average 2.4★
  • United StatesAbove only 20% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs LA avg
  • StaffingCan add or remove a star2★−0.4 vs LA avg
  • Quality measuresCan add or remove a star4★+2.0 vs LA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersLA avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 22% of peersLA avg2.4★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Top 9%LA avg2.0★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.86hrsAbove 63% of peersLA avg3.82Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.24hrsAbove only 48% of peersLA avg0.32Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better56%Above only 23% of peersLA avg48%RN turnover
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$168,036Above only 9% of peersLA avg$54,252Fines · denials3 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
28citations
7inspection dates
3actual harm (G–I)
0immediate jeopardy (J–L)
Jul 9, 2025most recent

Citations by monthJun 2023 – Jul 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Jul 9, 202511 citationsCycle 1worst E · no actual harm
  1. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Aug 4, 2025
  2. Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningE · patternCorrected Aug 4, 2025
  3. F908Keep all essential equipment working safely.EnvironmentalE · patternCorrected Aug 4, 2025
  4. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Aug 4, 2025
  5. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Aug 4, 2025
  6. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Aug 4, 2025
  7. F584Honor 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 RightsE · patternCorrected Aug 4, 2025
  8. F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident RightsD · isolatedCorrected Aug 4, 2025
  9. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Aug 4, 2025
  10. F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareD · isolatedCorrected Aug 4, 2025
  11. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 4, 2025
Nov 14, 20241 citationCycle 2worst D · no actual harm
  1. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected Dec 2, 2024
May 15, 20248 citationsCycle 2worst H · actual harm$151,769
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jun 12, 2024
  2. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareH · patternCorrected Jun 12, 2024
  3. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Jun 12, 2024
  4. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Jun 12, 2024
  5. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Jun 12, 2024
  6. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesE · patternCorrected Jun 12, 2024
  7. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jun 12, 2024
  8. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Jun 12, 2024
May 7, 20243 citationsCycle 2worst E · no actual harm$151,769
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected May 15, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected May 15, 2024
  3. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesE · patternCorrected Jun 12, 2024
Feb 15, 20243 citationsCycle 2worst G · actual harm$8,824
  1. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected Mar 8, 2024
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 8, 2024
  3. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Mar 8, 2024
Aug 17, 20231 citationCycle 3worst G · actual harm$7,443
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Aug 9, 2023
Jun 28, 20231 citationCycle 3worst D · no actual harm
  1. F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceD · isolatedCorrected Jul 14, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.86hrsAbove 63% of peers+0.04 vs LA avg
  • Registered nursesRN hours only0.24hrsAbove only 48% of peers−0.08 vs LA avg
  • Licensed practical nursesLPN hours1.19hrs
  • Nurse aidesCNA hours2.42hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.16hrs
  • Louisiana average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better56%Above only 23% of peersLA avg 48%
  • RN turnoverRegistered nurses onlyNot ranked by CMS
  • Administrators who leftIn the past year2Leadership changed
  • Occupancy150 certified beds · ~84 residents a day56%Above only 16% of peersLA avg 74%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $168,036In fines
  • 3Fines
  • 0Payment denials
  • $54,252LA avg in fines
Above only 9% of peersFewer fines than 9% of rated homes in Louisiana

Actions on record

  1. May 7, 2024Civil money penalty$151,769
  2. Feb 15, 2024Civil money penalty$8,824
  3. Aug 17, 2023Civil money penalty$7,443

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Legacy Nursing & Rehabilitation9 facilities in the chain1.8★ chain average
Certification
Medicare and Medicaid
Location type
Rural
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Dgprejean, LLC
  • Jdgum, LLC
  • Mylesh, LLC
  • Vdg LLC
Indirect owners (5%+)
  • John Gum
  • Victor Gum
  • Myles Holyfield
  • Danielle Prejean
Operational or managerial control
  • Legacy Management Group, LLC
  • Henry Thornton
Corporate directors
  • Victor Gum
Managing employees
  • Henry Thornton

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 195392 · 804 POLK STREET, WINNSBORO, LA, 71295.
  • Percentiles compare this facility with every rated nursing home in Louisiana and Franklin County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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