01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-08 | 19 | 2025-05-08 | 1 |
| Cycle 2 | 2024-03-29 | 10 | 2024-03-29 | 0 |
| Cycle 3 | 2023-01-27 | 10 | 2023-01-27 | 0 |
CMS CCN 4553512026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Legacy Nursing And Rehabilitation
2817 Kent Street · Bryan, TX 77802 · Brazos County
Certified beds117CMS provider file
Recent citation rows40current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
40 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 9 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-07-02 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has plan of correction · 2026-08-07 · complaint2026-02-05 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2026-02-06 · complaint2026-02-05 · HEALTHF0699Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
Correction field: Deficient, Provider has date of correction · 2026-02-06 · complaint2026-01-15 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-02-09 · complaint2025-12-04 · HEALTHF0755Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-12-05 · complaint2025-12-04 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-12-05 · complaint2025-06-11 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2025-07-10 · complaint2025-05-14 · HEALTHF0690Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2025-06-13 · complaint2025-05-08 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-08 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-08 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-08 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-08 · HEALTHF0688Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide 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.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-08 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-08 · HEALTHF0697Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-08 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-08 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-08 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure 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.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-08 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-08 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-08 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-08 · FIREK0923Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2025-06-182024-03-29 · HEALTHF0638Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
Correction field: Deficient, Provider has date of correction · 2024-04-242024-03-29 · HEALTHF0645Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2024-04-1903 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2026-01-15 | Fine | $12,375 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ANSON HOSPITAL DISTRICTOrganization · 5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 09/01/2025
- BRYAN PROPCO, L.L.C.Organization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2025
- VDG LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2025
- CLARK, JUSTAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 09/01/2025
- HAYNES, BILLIEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2016
- SPRABERRY, DAVIDIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2016
- KLEIN, PETEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2025
- LYTLE, LARRYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2025
- SHAW, MAXIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2025
- WILSON, TERIIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2025
- CLARK, JUSTAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/01/2025
- HAYNES, BILLIEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/01/2025
- SPRABERRY, DAVIDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/01/2025
- VEST, BARBARAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/01/2025
- ANSON HOSPITAL DISTRICTOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2025
- BRYAN OPCO LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2025
- DYMOCK, MATHEWIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/03/2025
- GUM, VICTORIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.00per resident day
RN hours0.23per resident day
Weekend nurse hours2.56per resident day
Staff turnover46.8%CMS reported field