Cycle 1
Health 2024-11-15 · Fire 2024-11-15
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Waxahachie, TX
Legend Oaks Healthcare And Rehabilitation - Waxaha
1-star overall rating with 2-star inspections with $41,215 in total fines with 12 recent health deficiencies
151 Country Meadows Boulevard, Waxahachie, TX
(972) 937-1650
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
121
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2017-01-31
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
Staffing
Hours and turnover
RN hours / resident day
0.37
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.33
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.38
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,177
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.42
Baseline 19.75% · Performance 19.85% · Measure score 3.42 · Achievement 3.42 · Improvement 0
Healthcare-associated infections
2.83
Baseline 6.91% · Performance 6.99% · Measure score 2.83 · Achievement 2.83 · Improvement 0
Total nurse turnover
0.9
Baseline 61.00% · Performance 60.00% · Measure score 0.9 · Achievement 0.9 · Improvement 0
Adjusted total nurse staffing
1.34
Baseline 2.97 hours · Performance 3.46 hours · Measure score 1.34 · Achievement 1.34 · Improvement 1.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.36% |
10.72%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 256 · Observed rate 17.19% · Lower 95% interval 10.07% |
| Discharge to community | 48.26% |
50.57%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 219 · Observed rate 41.55% · Lower 95% interval 40.57% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.08% |
95.27%
1.8 pts better
|
Numerator 133 · Denominator 137 |
| Falls with major injury | 0.73% |
0.77%
About the same
|
Numerator 1 · Denominator 137 |
| Discharge self-care score | 36.92% |
53.69%
16.8 pts worse
|
Numerator 24 · Denominator 65 |
| Discharge mobility score | 30.77% |
50.94%
20.2 pts worse
|
Numerator 20 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 137 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.99% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 7.09% · Lower 95% interval 4.77% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 149 |
| Staff flu vaccination coverage | 6.51% |
42%
35.5 pts worse
|
Numerator 14 · Denominator 215 |
| Discharge function score | 43.08% |
56.45%
13.4 pts worse
|
Numerator 28 · Denominator 65 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 44 · Denominator 44 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 53 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 72 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.1
1 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.6 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.1
0.9 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.3 · Expected 1.8 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
97.9%
0.9 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 1.3% · Q4 2.6% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
2.7%
2.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
3.3%
0.2 pts worse
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 2.9% · Q3 0.0% · Q4 1.4% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.8% |
18.9%
0.1 pts better
|
19.6%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 24.3% · Q3 16.4% · Q4 13.7% · 4Q avg 18.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.4% |
10.8%
3.4 pts better
|
16.7%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 6.9% · Q3 5.1% · Q4 5.0% · 4Q avg 7.4% · 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 | 34.5% |
15.4%
19.1 pts worse
|
16.3%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 40.1% · Q3 21.2% · Q4 40.2% · 4Q avg 34.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 36.1% |
16.1%
20 pts worse
|
14.9%
21.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 44.4% · Q3 41.0% · Q4 26.8% · 4Q avg 36.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
15.0%
7 pts worse
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 12.9% · Q3 21.4% · Q4 21.2% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.2%
0.1 pts worse
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.2% · Q3 8.0% · Q4 1.2% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
89.7%
9.9 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.1% |
12.0%
2.1 pts worse
|
12.0%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 14.7% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.3% |
88.0%
9.3 pts better
|
79.7%
17.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.4% |
25.9%
1.5 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 26.7% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-13 · Fire 2023-09-13
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-07-24 · Fire 2022-07-24
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-09-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-02-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-11-24
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 2025-12-01
D · Potential for more than minimal harm
2025-04-14
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 2025-05-12
G · Actual harm
2024-11-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-10
G · Actual harm
2024-11-15
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 2024-12-10
D · Potential for more than minimal harm
2024-11-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-15
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 2024-12-10
D · Potential for more than minimal harm
2024-11-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-06-17
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 2024-06-18
D · Potential for more than minimal harm
2024-06-17
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-06-17
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 2024-06-18
J · Immediate jeopardy
2024-03-07
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 2024-03-08
D · Potential for more than minimal harm
2024-03-07
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 2024-03-29
J · Immediate jeopardy
2024-02-07
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 2024-03-04
G · Actual harm
2024-02-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-04
E · Potential for more than minimal harm
2024-01-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-07
D · Potential for more than minimal harm
2023-10-05
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 2023-09-29
E · Potential for more than minimal harm
2023-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-13
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 2023-10-06
D · Potential for more than minimal harm
2023-09-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-06
K · Immediate jeopardy
2022-07-24
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 2022-08-15
K · Immediate jeopardy
2022-07-24
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 2022-08-15
F · Potential for more than minimal harm
2022-07-24
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 2022-08-15
E · Potential for more than minimal harm
2022-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-15
D · Potential for more than minimal harm
2022-07-24
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-08-15
Penalties and ownership
What sits behind the stars
$11,466
2024-11-15
Fine
Fine · fine $11,466
Fine
$15,851
2024-03-07
Fine
Fine · fine $15,851
Fine
$13,898
2024-01-23
Fine
Fine · fine $13,898
Fine
Ownership
Eastland Memorial Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Cow Creek Healthcare, Inc.
Operational/Managerial Control · Organization
Keetch, Chad
Corporate Officer · Individual
Muniz, Felicia
Operational/Managerial Control · Individual
Taylor, Stephen
Corporate Officer · Individual
Vassa, Neal
Operational/Managerial Control · Individual
Nearby options
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Focused Care of Waxahachie
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1-star overall rating with 1-star inspections with $159,939 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
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
#3
Red Oak Health And Rehabilitation Center
Red Oak, TX
4-star overall rating with 4-star inspections with $12,035 in total fines with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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