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
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
0.40
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.19
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
0.44
CMS adjusted RN staffing hours
Adjusted total hours
4.00
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,285
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.05
Baseline 19.53% · Performance 20.95% · Measure score 1.05 · Achievement 1.05 · Improvement 0
Healthcare-associated infections
6.90
Baseline 7.44% · Performance 5.77% · Measure score 6.90 · Achievement 6.90 · Improvement 6.31
Total nurse turnover
2.10
Baseline 59.09% · Performance 55.10% · Measure score 2.10 · Achievement 2.10 · Improvement 0.67
Adjusted total nurse staffing
0.86
Baseline 3.70 hours · Performance 3.32 hours · Measure score 0.86 · Achievement 0.86 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.54% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 15.63% · Lower 95% interval 7.79% |
| Discharge to community | 56.7% |
50.57%
6.1 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 50% · Lower 95% interval 41.9% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96.43% |
95.27%
1.2 pts better
|
Numerator 54 · Denominator 56 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 56 |
| Discharge self-care score | 45.16% |
53.69%
8.5 pts worse
|
Numerator 14 · Denominator 31 |
| Discharge mobility score | 41.94% |
50.94%
9 pts worse
|
Numerator 13 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 56 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.77% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 0% · Lower 95% interval 3.14% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 117 |
| Staff flu vaccination coverage | 30.81% |
42%
11.2 pts worse
|
Numerator 53 · Denominator 172 |
| Discharge function score | 45.16% |
56.45%
11.3 pts worse
|
Numerator 14 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 5.71% |
25.2%
19.5 pts worse
|
Numerator 2 · Denominator 35 |
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 · Adjusted 1.4 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| 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 · Adjusted 1.4 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| 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 · Q1 94.3% · Q2 97.4% · Q3 100.0% · Q4 100.0% · 4Q avg 97.9% |
| 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 | 1.0% |
3.3%
2.3 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 1.4% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| 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 · Q1 4.9% · Q2 2.5% · Q3 2.2% · Q4 2.0% · 4Q avg 2.8% |
| 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 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 6.0% · 4Q avg 2.2% |
| 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 · Q1 21.5% · Q2 19.4% · Q3 18.8% · Q4 20.6% · 4Q avg 20.1% |
| 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 · Q1 6.0% · Q2 4.1% · Q3 4.5% · Q4 3.9% · 4Q avg 4.6% · 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 | 14.4% |
15.4%
1 pts better
|
16.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 6.3% · Q3 17.2% · Q4 11.3% · 4Q avg 14.4% · Used in QM five-star |
| 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 · Q3 11.6% · Q4 42.2% · 4Q avg 27.7% · 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 | 15.5% |
15.0%
0.5 pts worse
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 6.5% · Q3 10.5% · Q4 13.8% · 4Q avg 15.5% |
| 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 · Q1 4.3% · Q2 1.9% · Q3 2.9% · Q4 1.2% · 4Q avg 2.6% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 98.2% · Q3 98.3% · Q4 98.6% · 4Q avg 98.8% |
| 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 · Adjusted 11.1% · Observed 12.1% · Expected 12.2% · Used in QM five-star |
| 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 · Q1 5.9% · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| 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 · 4Q avg 83.3% |
| 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 · Adjusted 25.0% · Observed 24.2% · Expected 23.1% · Used in QM five-star |
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
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#3
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