LEGEND OAKS HEALTHCARE AND REHABILITATION - WAXAHA
151 COUNTRY MEADOWS BOULEVARD, WAXAHACHIE, TX 75165 · CCN 676421
Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★☆☆☆ 2
- Staffing
- ★☆☆☆☆ 1
Facility
- Ownership type
- For profit - Individual
- Certified beds
- 121
- Avg residents/day
- 101.3
- Phone
- 9729371650
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2024-11-15 | 12 | 9.1 | 9.5 | +2.9 worse |
| 2 | 2023-09-13 | 10 | 9.4 | 9.8 | +0.6 worse |
| 3 | 2022-07-24 | 11 | 8.1 | 9.3 | +2.9 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 1 |
| Quality of life and care | 2 |
| Resident assessment and care planning | 4 |
| Resident rights | 2 |
| Nutrition and dietary | 1 |
| Pharmacy service | 1 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.33 | 59.0% |
| RN staffing (reported) | 0.37 | 62.5% |
| Total nurse staffing (adjusted) | 3.38 | — |
Fines & penalties
- Total fines
- $41,215
- Number of fines
- 3
- Number of penalties
- 3
- Payment denials
- 0
Chain
- Chain
- THE ENSIGN GROUP
- Facilities in chain
- 329
- Chain avg overall
- 3.20 / 5
Inspection citations (33)4 immediate jeopardy3 actual harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-12-12 · Health · corrected 2025-12-15
Potential for more than minimal harm
- DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2025-11-24 · Health · corrected 2025-12-01
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-04-14 · Health · corrected 2025-05-12
Potential for more than minimal harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2024-11-15 · Health · corrected 2024-12-10
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-11-15 · Health · corrected 2024-12-10
Potential for more than minimal harm
- DF0641Ensure each resident receives an accurate assessment.2024-11-15 · Health · corrected 2024-12-10
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-11-15 · Health · corrected 2024-12-10
Potential for more than minimal harm
- GF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-11-15 · Health · corrected 2024-12-10
Actual harm
- GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-11-15 · Health · corrected 2024-12-10
Actual harm
- DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2024-11-15 · Health · corrected 2024-12-10
Potential for more than minimal harm
- DF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2024-11-15 · Health · corrected 2024-12-10
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2024-11-15 · Health · corrected 2024-12-10
Potential for more than minimal harm
- DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-06-17 · Health · corrected 2024-06-18
Potential for more than minimal harm
- DF0584Honor 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.2024-06-17 · Health · corrected 2024-06-18
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-06-17 · Health · corrected 2024-06-18
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-03-07 · Health · corrected 2024-03-29
Potential for more than minimal harm
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-03-07 · Health · corrected 2024-03-08
Immediate jeopardy
- GF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-02-07 · Health · corrected 2024-03-04
Actual harm
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-02-07 · Health · corrected 2024-03-04
Immediate jeopardy
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-01-23 · Health · corrected 2024-02-07
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-01-23 · Health · corrected 2024-02-07
Potential for more than minimal harm
- EF0761Ensure 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.2024-01-23 · Health · corrected 2024-02-07
Potential for more than minimal harm
- DF0693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.2023-10-05 · Health · corrected 2023-09-29
Potential for more than minimal harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2023-09-13 · Health · corrected 2023-10-06
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-09-13 · Health · corrected 2023-10-06
Potential for more than minimal harm
- DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2023-09-13 · Health · corrected 2023-10-06
Potential for more than minimal harm
- DF0760Ensure that residents are free from significant medication errors.2023-09-13 · Health · corrected 2023-10-06
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2023-09-13 · Health · corrected 2023-10-06
Potential for more than minimal harm
- KF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2022-07-24 · Health · corrected 2022-08-15
Immediate jeopardy
- KF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2022-07-24 · Health · corrected 2022-08-15
Immediate jeopardy
- DF0761Ensure 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.2022-07-24 · Health · corrected 2022-08-15
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-07-24 · Health · corrected 2022-08-15
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2022-07-24 · Health · corrected 2022-08-15
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| EASTLAND MEMORIAL HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2019-04-01 |
| COW CREEK HEALTHCARE, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2019-04-01 |
| MUNIZ, FELICIA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-01-31 |
| VASSA, NEAL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2018-05-30 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | — | 2017-01-31 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | — | 2011-03-01 |
| TAYLOR, STEPHEN | Individual | CORPORATE OFFICER | — | 2025-07-01 |
Other facilities in WAXAHACHIE
| Name | Overall | Beds |
|---|---|---|
| PLEASANT MANOR HEALTHCARE REHABILITATION | ★★★☆☆ | 132 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.