Nursing home in Waxahachie, Texas
Legend Oaks Healthcare and Rehabilitation - Waxaha
Medicare and Medicaid
151 Country Meadows Boulevard, Waxahachie, TX 75165
(972) 937-1650
CMS star ratings
CMS gives this nursing home an overall star rating of 1 out of 5. Each rating is compared with the mean of rated nursing homes in Texas (1,165 for the overall rating) and in the U.S. (14,565). How to read an inspection report.
Overall rating
- This nursing home1
- Texas average2.7 (1,165 rated)
- U.S. average3.0 (14,565 rated)
Health inspections
- This nursing home2
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
- This nursing home1
- Texas average1.9 (1,163 rated)
- U.S. average2.9 (14,494 rated)
Quality measures
- This nursing home3
- Texas average3.7 (1,162 rated)
- U.S. average3.6 (14,495 rated)
Health inspections
Most recent standard health inspection (rating cycle 1): Feb 12, 2026. CMS counts 10 health deficiencies in rating cycle 1.
- This nursing home10
- Texas average9.4 (1,171 with data)
- U.S. average9.2 (14,652 with data)
Rating cycle 1 health deficiencies. Averages include every nursing home with a count in the CMS file; fewer is better.
Deficiencies since Sep 30, 2023
Inspectors cited 31 health deficiencies on 12 inspection dates since Sep 30, 2023. By level of harm: 2 immediate jeopardy, 3 actual harm, 26 potential for harm.
- 2 Immediate jeopardy to resident health or safety
- 3 Actual harm
- 26 No actual harm, potential for more than minimal harm
- 0 No actual harm, potential for minimal harm
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Jul 25, 2026 | F0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Aug 14, 2026 |
| Apr 15, 2026 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident Rights Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Apr 17, 2026 |
| Apr 15, 2026 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Apr 17, 2026 |
| Feb 12, 2026 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Mar 16, 2026 |
| Feb 12, 2026 | F0850 | Hire a qualified full-time social worker in a facility with more than 120 beds.Administration Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Mar 16, 2026 |
| Feb 12, 2026 | F0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Mar 16, 2026 |
| Feb 12, 2026 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Mar 16, 2026 |
| Feb 12, 2026 | F0761 | 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.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Mar 16, 2026 |
| Dec 12, 2025 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 15, 2025 |
| Nov 24, 2025 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 1, 2025 |
Show the other 21 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Apr 14, 2025 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction May 12, 2025 |
| Nov 15, 2024 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and Care Deficiencies | G Actual harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Dec 10, 2024 |
| Nov 15, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | G Actual harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Dec 10, 2024 |
| Nov 15, 2024 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 10, 2024 |
| Nov 15, 2024 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and Exploitation Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Dec 10, 2024 |
| Nov 15, 2024 | F0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 10, 2024 |
| Nov 15, 2024 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 10, 2024 |
| Nov 15, 2024 | F0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 10, 2024 |
| Nov 15, 2024 | F0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and Dietary Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 10, 2024 |
| Nov 15, 2024 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 10, 2024 |
| Jun 17, 2024 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jun 18, 2024 |
| Jun 17, 2024 | F0584 | 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.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jun 18, 2024 |
| Jun 17, 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jun 18, 2024 |
| Mar 7, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | J Immediate jeopardy, isolated | Complaint | Deficient, Provider has date of correction Mar 8, 2024 |
| Mar 7, 2024 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Mar 29, 2024 |
| Feb 7, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | J Immediate jeopardy, isolated | Complaint | Deficient, Provider has date of correction Mar 4, 2024 |
| Feb 7, 2024 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and Care Deficiencies | G Actual harm, isolated | Complaint | Deficient, Provider has date of correction Mar 4, 2024 |
| Jan 23, 2024 | F0761 | 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.Pharmacy Service Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Feb 7, 2024 |
| Jan 23, 2024 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Feb 7, 2024 |
| Jan 23, 2024 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Feb 7, 2024 |
| Oct 5, 2023 | F0693 | 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.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Past Non-Compliance Sep 29, 2023 |
Staffing
Total nurse staffing
Reported hours per resident per day.
- This nursing home3.55 hours
- Texas average3.39 hours (1,148 with data)
- U.S. average3.86 hours (14,351 with data)
Registered nurse staffing
Reported hours per resident per day.
- This nursing home0.25 hours
- Texas average0.43 hours (1,148 with data)
- U.S. average0.69 hours (14,351 with data)
Nursing staff turnover
Share of nursing staff who left during the year, as reported to CMS.
- This nursing home57.6%
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 3 penalties for this nursing home: 3 fines totaling $41,215, and 0 payment denials. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 121 |
|---|---|
| Average residents per day | 101.7 |
| Ownership | For profit - Individual |
| Provider type | Medicare and Medicaid |
| Inside a hospital | No |
| Continuing care retirement community | No |
| Resident and family council | Both |
| Automatic sprinklers in all required areas | Yes |
| Chain | The Ensign Group (344 facilities) |
| Legal business name | EASTLAND MEMORIAL HOSPITAL DISTRICT |
| First approved for Medicare and Medicaid | Jan 31, 2017 |
| County | Ellis |
| CMS certification number | 676421 |
Also in Waxahachie
| Nursing home | CMS overall rating | Health inspection rating | Certified beds | Ownership |
|---|---|---|---|---|
| Pleasant Manor Healthcare and Rehabilitation | 132 | For profit - Limited Liability company | ||
| Focused Care of Waxahachie | 152 | Government - Hospital district |
| Hospital | CMS overall rating | Type | Emergency services |
|---|---|---|---|
| Baylor Scott & White Medical Center- Waxahachie | Acute Care Hospitals | Yes |