Cycle 1
Health 2025-01-10 · Fire 2025-01-10
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Waxahachie, TX
Pleasant Manor Healthcare Rehabilitation
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
3650 S Ih 35 E, Waxahachie, TX
(972) 937-7320
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2001-10-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing
LPN hours / resident day
0.96
Licensed practical nurse staffing
Aide hours / resident day
2.34
Nurse aide staffing
Weekend hours
3.13
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
51%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
97.1%
0.8 pts better
|
93.4%
4.5 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 | 1.0% |
3.3%
2.3 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
2.7%
0.1 pts worse
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.2% |
3.3%
1.1 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
18.9%
1.2 pts worse
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 4.6% |
10.8%
6.2 pts better
|
16.7%
12.1 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 | 14.4% |
15.4%
1 pts better
|
16.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.7% |
16.1%
11.6 pts worse
|
14.9%
12.8 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.2%
1.6 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
89.7%
9.1 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.1% |
12.0%
0.9 pts better
|
12.0%
0.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.5%
1 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.3% |
88.0%
4.7 pts worse
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
25.9%
0.9 pts better
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-15 · Fire 2023-11-15
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-15 · Fire 2022-09-15
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-10
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 2025-03-18
F · Potential for more than minimal harm
2025-01-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-01-10
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 2025-03-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-10
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 2025-02-01
E · Potential for more than minimal harm
2025-01-10
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 2025-02-01
D · Potential for more than minimal harm
2025-01-10
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 2025-02-01
D · Potential for more than minimal harm
2025-01-10
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 2025-02-03
D · Potential for more than minimal harm
2025-01-10
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 2025-02-01
D · Potential for more than minimal harm
2025-01-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-01
D · Potential for more than minimal harm
2025-01-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-01
D · Potential for more than minimal harm
2025-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-01
J · Immediate jeopardy
2024-02-14
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 2024-03-04
J · Immediate jeopardy
2024-02-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-14
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 2024-03-04
F · Potential for more than minimal harm
2023-11-15
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 2023-12-06
E · Potential for more than minimal harm
2023-11-15
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 2023-12-06
E · Potential for more than minimal harm
2023-11-15
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 2023-12-06
E · Potential for more than minimal harm
2023-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-06
E · Potential for more than minimal harm
2022-09-15
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 2022-10-15
E · Potential for more than minimal harm
2022-09-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-09-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-15
Penalties and ownership
What sits behind the stars
$14,996
2024-02-14
Fine
Fine · fine $14,996
Fine
Ownership
Eastland Memorial Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Hardrick, Chasidy
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Laheji, Junaid
Operational/Managerial Control · Individual
Percheron Healthcare, Inc.
Operational/Managerial Control · Organization
Taylor, Stephen
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Focused Care of Waxahachie
Waxahachie, TX
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
Legend Oaks Healthcare And Rehabilitation - Waxaha
Waxahachie, TX
1-star overall rating with 2-star inspections with $41,215 in total fines with 12 recent health deficiencies
#3
Midtowne Meadows Health & Rehab
Midlothian, TX
5-star overall rating with 5-star inspections with $20,131 in total fines with 1 fire-safety deficiencies in the latest cycle
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