LEGEND OAKS HEALTHCARE AND REHABILITATION - WAXAHA

151 COUNTRY MEADOWS BOULEVARD
WAXAHACHIE, TX, 75165
9729371650
CCN: 676421
1
Overall
2
Health
1
Staffing
2
Quality
ChainTHE ENSIGN GROUP
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
EASTLAND MEMORIAL HOSPITAL DISTRICT5% OR GREATER DIRECT OWNERSHIP INTEREST100%
BURNAM, SOONCORPORATE OFFICERNOT APPLICABLE
KEETCH, CHADCORPORATE OFFICERNOT APPLICABLE
TAYLOR, STEPHENCORPORATE OFFICERNOT APPLICABLE
VASSA, NEALOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
COW CREEK HEALTHCARE, INC.OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
MUNIZ, FELICIAOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (3)
DateTypeAmount
2024-11-15Fine$11K
2024-03-07Fine$16K
2024-01-23Fine$14K
Health Deficiencies (33)
2025-12-12 · Health
D
F842 · 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.
2025-11-24 · Health
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2025-04-14 · Health
D
F656 · 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.
2024-11-15 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
D
F757 · Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
G
F689 · 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
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F656 · 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
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F609 · 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
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2024-06-17 · Health
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F584 · 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
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2024-03-07 · Health
J
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F656 · 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.
2024-02-07 · Health
J
F689 · 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
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2024-01-23 · Health
E
F761 · 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
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F580 · 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.
2023-10-05 · Health
D
F693 · 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.
2023-09-13 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
D
F690 · 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
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2022-07-24 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F761 · 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.
K
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
K
F656 · 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.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.33
3.68
RN Hrs/Resident/Day
0.37
0.54
LPN Hrs/Resident/Day
0.90
0.81
CNA Hrs/Resident/Day
2.05
2.33
PT Hrs/Resident/Day
0.07
0.12
Data as of 2026-03-01