SeniorHomeViolations
C+
67/100

Pleasant Manor Healthcare and Rehabilitation Inspection Report, Violations & Safety Grade (Waxahachie, Texas)

3650 S. Interstate 35 E, Waxahachie, Texas 75165

Phone: 9729377320

CMS Overall:3/5

Overview & Bed Count

Certified Beds
132
Avg Residents/Day
88.3
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Ellis
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall3/5
Health2/5
Staffing2/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityTexas AvgDifference
RN Hours per Resident per Day0.580.44+0.14
Total Nurse Hours per Resident per Day3.453.42+0.04
CMS Staffing Rating2/51.9/5-
Nursing Staff Turnover56.2%50.8%-

Health Citation History

29 health citations on record

DateCategoryDescriptionSeverity
2026-04-10Nutrition and Dietary DeficienciesEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.E – Moderate Harm Potential
2026-04-10Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2026-03-05Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.E – Moderate Harm Potential
2026-03-05Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.E – Moderate Harm Potential
2026-03-05Administration DeficienciesHire a qualified full-time social worker in a facility with more than 120 beds.E – Moderate Harm Potential
2026-03-05Resident Rights DeficienciesReasonably accommodate the needs and preferences of each resident.D – Moderate Harm Potential
2026-03-05Resident Rights DeficienciesImmediately 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
2026-03-05Resident Rights DeficienciesHonor 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
2026-03-05Freedom from Abuse, Neglect, and Exploitation DeficienciesPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.D – Moderate Harm Potential
2026-03-05Resident Assessment and Care Planning DeficienciesDevelop 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
2026-03-05Quality of Life and Care DeficienciesProvide care and assistance to perform activities of daily living for any resident who is unable.D – Moderate Harm Potential
2026-03-05Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2026-03-05Environmental DeficienciesKeep all essential equipment working safely.D – Moderate Harm Potential
2025-01-10Pharmacy Service DeficienciesEnsure 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
2025-01-10Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2025-01-10Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D – Moderate Harm Potential
2025-01-10Resident Assessment and Care Planning DeficienciesCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.D – Moderate Harm Potential
2025-01-10Resident Assessment and Care Planning DeficienciesDevelop 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
2025-01-10Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2025-01-10Pharmacy Service DeficienciesEnsure each resident’s drug regimen must be free from unnecessary drugs.D – Moderate Harm Potential
2025-01-10Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2024-02-14Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.J – Immediate Jeopardy
2024-02-14Quality of Life and Care DeficienciesProvide safe, appropriate pain management for a resident who requires such services.J – Immediate Jeopardy
2024-02-14Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D – Moderate Harm Potential
2023-11-15Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2023-11-15Resident Rights DeficienciesImmediately 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
2023-11-15Resident Assessment and Care Planning DeficienciesCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.E – Moderate Harm Potential
2023-11-15Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2023-11-15Quality of Life and Care DeficienciesProvide appropriate pressure ulcer care and prevent new ulcers from developing.D – Moderate Harm Potential

Fire Safety Citation History

3 fire safety citations on record

DateCategoryDescriptionSeverity
2025-01-10Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.F – Moderate Harm Potential
2025-01-10Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.F – Moderate Harm Potential
2025-01-10Miscellaneous DeficienciesHave posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.D – Moderate Harm Potential

Total Penalties & Fines

$24,106
Total Fine Amount (CMS)
2
Number of Fines
2
Total Penalties
DateTypeFine AmountPayment Denial
2026-03-05Fine$9,110-
2024-02-14Fine$14,996-

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