Cycle 1
Health 2025-02-27 · Fire 2025-02-27
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Ennis, TX
Legend Oaks Healthcare And Rehabilitation - Ennis
5-star overall rating with 5-star inspections with $13,275 in total fines with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1400 Medical Center Drive, Ennis, TX
(972) 875-4800
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
73
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2010-06-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing
LPN hours / resident day
1.02
Licensed practical nurse staffing
Aide hours / resident day
2.11
Nurse aide staffing
Weekend hours
2.76
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
36%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.3%
1.5 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
2.7%
1.5 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.8% |
3.3%
1.5 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.4% |
18.9%
6.5 pts worse
|
19.6%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 3.4% |
10.8%
7.4 pts better
|
16.7%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.0% |
15.4%
7.6 pts worse
|
16.3%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
16.1%
1.2 pts worse
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
0.8%
0.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.7% |
15.0%
5.7 pts worse
|
19.8%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
4.2%
3.3 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
12.0%
2.2 pts worse
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
88.0%
9 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.1% |
25.9%
0.2 pts worse
|
23.9%
2.2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
5 health deficiencies
Top issue: Environmental (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-12-01 · Fire 2022-12-01
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-02-27
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-02-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-02-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-02-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-27
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2025-02-27
F · Potential for more than minimal harm
2024-01-11
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-01-11
F · Potential for more than minimal harm
2022-12-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-28
F · Potential for more than minimal harm
2022-12-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-05
F · Potential for more than minimal harm
2022-12-01
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-07-17
E · Potential for more than minimal harm
2022-12-01
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-27
E · Potential for more than minimal harm
2022-12-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-27
D · Potential for more than minimal harm
2022-12-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-27
D · Potential for more than minimal harm
2022-12-01
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-06-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-07-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-07-01
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-01-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-18
E · Potential for more than minimal harm
2024-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-18
E · Potential for more than minimal harm
2024-01-11
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-01-18
J · Immediate jeopardy
2023-08-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-03
E · Potential for more than minimal harm
2022-12-01
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-01-13
E · Potential for more than minimal harm
2022-12-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-01
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-01-13
Penalties and ownership
What sits behind the stars
$13,275
2023-08-17
Fine
Fine · fine $13,275
Fine
Ownership
Eastland Memorial Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Getzendaner Healthcare, Inc.
Operational/Managerial Control · Organization
Keetch, Chad
Corporate Officer · Individual
Miller, Roy
Operational/Managerial Control · Individual
Sharma, Neeraj
Operational/Managerial Control · Individual
Taylor, Stephen
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Ennis Care Center
Ennis, TX
1-star overall rating with 2-star inspections with $187,220 in total fines with 8 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Bluebonnet Rehab At Ennis
Ennis, TX
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Pleasant Manor Healthcare Rehabilitation
Waxahachie, TX
3-star overall rating with 3-star inspections with $14,996 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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