D+
51/100Legend Oaks Healthcare and Rehabilitation - Waxaha Inspection Report, Violations & Safety Grade (Waxahachie, Texas)
151 Country Meadows Boulevard, Waxahachie, Texas 75165
Phone: 9729371650
CMS Overall:1/5
Overview & Bed Count
Certified Beds
121
Avg Residents/Day
101.9
Ownership
For profit - Individual
Provider Type
Medicare and Medicaid
County
Ellis
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health2/5
Staffing1/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Texas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.25 | 0.44 | -0.19 |
| Total Nurse Hours per Resident per Day | 3.59 | 3.42 | +0.18 |
| CMS Staffing Rating | 1/5 | 1.9/5 | - |
| Nursing Staff Turnover | 60.9% | 50.8% | - |
Health Citation History
36 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-25 | Resident Assessment and Care Planning Deficiencies | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D – Moderate Harm Potential |
| 2026-04-15 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | E – Moderate Harm Potential |
| 2026-04-15 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E – Moderate Harm Potential |
| 2026-02-12 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2026-02-12 | Administration Deficiencies | Hire a qualified full-time social worker in a facility with more than 120 beds. | E – Moderate Harm Potential |
| 2026-02-12 | Resident Assessment and Care Planning Deficiencies | PASARR screening for Mental disorders or Intellectual Disabilities | D – Moderate Harm Potential |
| 2026-02-12 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2026-02-12 | 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. | D – Moderate Harm Potential |
| 2025-12-12 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2025-11-24 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-04-14 | 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. | D – Moderate Harm Potential |
| 2024-11-15 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G – Actual Harm |
| 2024-11-15 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2024-11-15 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | D – Moderate Harm Potential |
| 2024-11-15 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-11-15 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2024-11-15 | 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. | D – Moderate Harm Potential |
| 2024-11-15 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2024-11-15 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | D – Moderate Harm Potential |
| 2024-11-15 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2024-06-17 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2024-06-17 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-06-17 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2024-03-07 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2024-03-07 | 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. | D – Moderate Harm Potential |
| 2024-02-07 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2024-02-07 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G – Actual Harm |
| 2024-01-23 | 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. | E – Moderate Harm Potential |
| 2024-01-23 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2024-01-23 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2023-10-05 | Quality of Life and Care Deficiencies | Ensure 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. | D – Moderate Harm Potential |
| 2023-09-13 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2023-09-13 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | D – Moderate Harm Potential |
| 2023-09-13 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2023-09-13 | 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. | D – Moderate Harm Potential |
| 2023-09-13 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
Fire Safety Citation History
1 fire safety citation on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2023-09-13 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | E – Moderate Harm Potential |
Total Penalties & Fines
$41,215
Total Fine Amount (CMS)
3
Number of Fines
3
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-11-15 | Fine | $11,466 | - |
| 2024-03-07 | Fine | $15,851 | - |
| 2024-01-23 | Fine | $13,898 | - |
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Waxahachie area at no cost.
Find Safe, Vetted Facilities Near Waxahachie
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.