Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Legacy Nursing and Rehabilitation of Morgan City

Morgan City, LA · 88 certified beds · Last Life Safety survey August 7, 2025

CMS Certification Number 195386 · first certified October 1996

Ownership

Operated by LEGACY NURSING & REHABILITATION · For profit - Corporation

  • Ownership changed January 1, 2020 (change of ownership)from PINNACLE HEALTH FACILITIES OF LOUISIANA, LLC
21
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
2
Tags cited more than once
Across separate surveys
9
Inspection & testing records
Of the citations on file

Position within LA

21 citations — more than 100% of the 265 certified nursing homes in LA. Compared within LA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 2 citations; the earlier surveys in the window averaged 9.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Past the typical window (July 2026 to September 2026). Most LA facilities have been surveyed by October 2026. This facility’s last Life Safety survey was August 2025. Facilities in LA are typically surveyed 12–13 months after the last one (median 13), measured over 458 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

10 of the 21 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 21 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in LA, and nationally. Surveyors differ markedly between states, so the LA figure is the meaningful one.

This facility21LA median2National median11
Citations on file over three years, compared
MeasureCitations
This facility21
Median facility in LA2
Median facility nationally11

Survey history

Citations at each Life Safety survey
162023-1032024-0822025-08
Citations at each Life Safety survey
Survey dateCitations
October 5, 202316
August 22, 20243
August 7, 20252

Most-cited tags

Most-cited tags at this facility
K-03533K-05213E-00181K-03511E-00361E-00221K-07411E-00061
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0353Inspect, test, and maintain automatic sprinkler systems.32025-08-07
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.32025-08-07
E-0018Establish procedures for tracking staff and patients during an emergency.12023-10-05
K-0351Install an approved automatic sprinkler system.12023-10-05
E-0036Establish emergency prep training and testing.12023-10-05
E-0022Establish policies and procedures for sheltering.12023-10-05
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.12023-10-05
E-0006Conduct risk assessment and an All-Hazards approach.12023-10-05

What the citations cover

Citations by CMS category
  • Emergency Preparedness Deficiencies 10
  • Smoke Deficiencies 5
  • Services Deficiencies 3
  • Miscellaneous Deficiencies 2
  • Other 1
Citations by CMS category
CategoryCitations
Emergency Preparedness Deficiencies10
Smoke Deficiencies5
Services Deficiencies3
Miscellaneous Deficiencies2
Gas, Vacuum, and Electrical Systems Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

August 7, 2025 — 2 citations

Citations issued on August 7, 2025
TagWhat the surveyor checksStatus
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (September 15, 2025)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (September 15, 2025)

August 22, 2024 — 3 citations

Citations issued on August 22, 2024
TagWhat the surveyor checksStatus
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (September 26, 2024)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Waiver has been granted
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (September 26, 2024)

October 5, 2023 — 16 citations

Citations issued on October 5, 2023
TagWhat the surveyor checksStatus
E-0001Establish an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (November 14, 2023)
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (November 14, 2023)
E-0006Conduct risk assessment and an All-Hazards approach.Deficient, Provider has date of correction (November 14, 2023)
E-0013Develop Emergency Preparedness policies and procedures.Deficient, Provider has date of correction (November 14, 2023)
E-0018Establish procedures for tracking staff and patients during an emergency.Deficient, Provider has date of correction (November 14, 2023)
E-0022Establish policies and procedures for sheltering.Deficient, Provider has date of correction (November 14, 2023)
E-0032Provide primary/alternate means for communication.Deficient, Provider has date of correction (November 14, 2023)
E-0033Establish methods for sharing information.Deficient, Provider has date of correction (November 14, 2023)
E-0036Establish emergency prep training and testing.Deficient, Provider has date of correction (November 14, 2023)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (November 14, 2023)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (December 5, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (November 1, 2023)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (November 1, 2023)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (November 1, 2023)
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.Deficient, Provider has date of correction (November 1, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (November 1, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.