Cycle 1
Health 2024-12-19 · Fire 2024-12-19
4 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Keller, TX
Legend Oaks Healthcare and Rehabilitation - Fort W
4-star overall rating with 4-star inspections with $50,633 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4240 Golden Triangle Boulevard, Keller, TX
(817) 806-6400
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2017-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.75
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.21
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.70
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
77%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,079
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9907
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.17
Baseline 19.45% · Performance 19.04% · Measure score 5.17 · Achievement 5.17 · Improvement 1.23
Healthcare-associated infections
7.32
Baseline 7.13% · Performance 5.65% · Measure score 7.32 · Achievement 7.32 · Improvement 6.45
Total nurse turnover
0.85
Baseline 69.12% · Performance 63.16% · Measure score 0.85 · Achievement 0 · Improvement 0.85
Adjusted total nurse staffing
1.65
Baseline 2.58 hours · Performance 3.27 hours · Measure score 1.65 · Achievement 0.68 · Improvement 1.65
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.83% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 15.15% · Lower 95% interval 8.59% |
| Discharge to community | 48.79% |
50.57%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 41.33% · Lower 95% interval 38.73% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.12% |
95.27%
1.9 pts better
|
Numerator 101 · Denominator 104 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 104 |
| Discharge self-care score | 45.16% |
53.69%
8.5 pts worse
|
Numerator 28 · Denominator 62 |
| Discharge mobility score | 51.61% |
50.94%
0.7 pts better
|
Numerator 32 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 104 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.65% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 2.82% · Lower 95% interval 3.05% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 159 |
| Staff flu vaccination coverage | 22.41% |
42%
19.6 pts worse
|
Numerator 54 · Denominator 241 |
| Discharge function score | 64.52% |
56.45%
8.1 pts better
|
Numerator 40 · Denominator 62 |
| Transfer of health information to provider | 81.82% |
95.95%
14.1 pts worse
|
Numerator 27 · Denominator 33 |
| Transfer of health information to patient | 97.14% |
96.28%
0.9 pts better
|
Numerator 34 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 2.04% |
25.2%
23.2 pts worse
|
Numerator 1 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 3.0 · Expected 3.0 · Used in QM five-star |
| 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 · Adjusted 2.3 · Observed 2.9 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
97.1%
1.6 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 99.0% · Q3 97.9% · Q4 100.0% · 4Q avg 98.7% |
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 3.1% · Q4 5.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
2.7%
1 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 2.5% · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
3.3%
1.2 pts worse
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 2.2% · Q3 2.3% · Q4 5.9% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.9% |
18.9%
6 pts better
|
19.6%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 16.5% · Q3 9.0% · Q4 6.8% · 4Q avg 12.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.6% |
10.8%
7.2 pts better
|
16.7%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.6% · Q3 2.7% · Q4 7.5% · 4Q avg 3.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.5% |
15.4%
0.9 pts better
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 25.6% · Q3 19.3% · Q4 6.4% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
16.1%
2.7 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 40.0% · Q3 18.5% · Q4 7.6% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
15.0%
0.5 pts worse
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 12.0% · Q3 8.1% · Q4 16.3% · 4Q avg 15.5% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.2%
0.5 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.1% · Q3 4.7% · Q4 3.5% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
89.7%
0.5 pts better
|
81.7%
8.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.4% · Q2 90.4% · Q3 90.0% · Q4 89.8% · 4Q avg 90.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.9% |
12.0%
2.9 pts worse
|
12.0%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 18.2% · Expected 13.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 1.7% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.9% |
88.0%
12.1 pts worse
|
79.7%
3.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
25.9%
2.4 pts better
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 28.4% · Expected 28.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
10 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2022-09-22 · Fire 2022-09-22
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-20
F · Potential for more than minimal harm
2023-11-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-11
F · Potential for more than minimal harm
2023-11-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-11
F · Potential for more than minimal harm
2022-09-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-04
Inspection history
Recent health citations
J · Immediate jeopardy
2025-09-11
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 2025-07-29
G · Actual harm
2025-02-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-30
D · Potential for more than minimal harm
2024-12-19
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-12-19
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-12-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-20
J · Immediate jeopardy
2024-10-08
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 2024-09-23
D · Potential for more than minimal harm
2024-10-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-06-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-06-06
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-06-30
E · Potential for more than minimal harm
2023-11-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-11-16
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 2023-11-17
D · Potential for more than minimal harm
2023-11-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-11-16
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-11-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-17
J · Immediate jeopardy
2023-05-25
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 2023-05-13
E · Potential for more than minimal harm
2022-09-22
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 2022-10-18
E · Potential for more than minimal harm
2022-09-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-09-22
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 2022-10-18
Penalties and ownership
What sits behind the stars
$10,361
2025-09-11
Fine
Fine · fine $10,361
Fine
$9,110
2025-02-26
Fine
Fine · fine $9,110
Fine
$8,827
2024-10-08
Fine
Fine · fine $8,827
Fine
$22,335
2023-05-25
Fine
Fine · fine $22,335
Fine
Ownership
Eastland Memorial Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Cantrell, Christopher
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Nb Brown Rock Healthcare, Inc.
Operational/Managerial Control · Organization
Porter, Kris
Operational/Managerial Control · Individual
Taylor, Stephen
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
The Harrison at Heritage
Fort Worth, TX
4-star overall rating with 3-star inspections with $65,529 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Heritage House At Keller Rehab & Nursing
Keller, TX
5-star overall rating with 4-star inspections with $30,371 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Green Valley Healthcare and Rehabilitation Center
Fort Worth, TX
2-star overall rating with 1-star inspections with $106,265 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Jump out