Cycle 1
Health 2024-09-19 · Fire 2024-09-19
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Plano, TX
The Legacy At Willow Bend
5-star overall rating with 4-star inspections with 6 recent health deficiencies
6101 Ohio Ste 500, Plano, TX
(972) 468-6300
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
59
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-07-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.00
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
3.44
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
5.41
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.98
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.85
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
5.33
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,874
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9953
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.05
Baseline 21.43% · Performance 20.94% · Measure score 1.05 · Achievement 1.05 · Improvement 0.61
Healthcare-associated infections
2.80
Baseline 5.32% · Performance 7.00% · Measure score 2.80 · Achievement 2.80 · Improvement 0
Total nurse turnover
6.24
Baseline 56.63% · Performance 38.16% · Measure score 6.24 · Achievement 6.24 · Improvement 5.31
Adjusted total nurse staffing
6.83
Baseline 4.75 hours · Performance 5.02 hours · Measure score 6.83 · Achievement 6.83 · Improvement 2.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.5% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 464 · Observed rate 12.5% · Lower 95% interval 10.29% |
| Discharge to community | 67.59% |
50.57%
17 pts better
|
Better than the National Rate · Eligible stays 424 · Observed rate 61.79% · Lower 95% interval 62.72% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 295 · Denominator 295 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 295 |
| Discharge self-care score | 57.8% |
53.69%
4.1 pts better
|
Numerator 126 · Denominator 218 |
| Discharge mobility score | 51.38% |
50.94%
0.4 pts better
|
Numerator 112 · Denominator 218 |
| Pressure ulcers or injuries, new or worsened | 0.34% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 295 · Adjusted rate 0.41% |
| Healthcare-associated infections requiring hospitalization | 7% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 279 · Observed rate 6.45% · Lower 95% interval 4.97% |
| Staff COVID-19 vaccination coverage | 27.83% |
8.2%
19.6 pts better
|
Numerator 32 · Denominator 115 |
| Staff flu vaccination coverage | 29.03% |
42%
13 pts worse
|
Numerator 36 · Denominator 124 |
| Discharge function score | 60.09% |
56.45%
3.6 pts better
|
Numerator 131 · Denominator 218 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 85 · Denominator 85 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 189 · Denominator 189 |
| Resident COVID-19 vaccinations up to date | 89.68% |
25.2%
64.5 pts better
|
Numerator 139 · Denominator 155 |
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 2.3 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.7 · 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 | 92.6% |
97.9%
5.3 pts worse
|
95.5%
2.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 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 who have depressive symptoms | 7.5% |
2.7%
4.8 pts worse
|
11.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 8.7% · Q3 9.1% · Q4 0.0% · 4Q avg 7.5% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.1% |
18.9%
16.2 pts worse
|
19.6%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 28.6% · 4Q avg 35.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
10.8%
0.1 pts worse
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% · 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 need for help with daily activities has increased | 9.0% |
16.1%
7.1 pts better
|
14.9%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 5.0% · 4Q avg 9.0% · 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 · 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 | 16.7% |
15.0%
1.7 pts worse
|
19.8%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 25.1% · 4Q avg 16.7% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
4.2%
3.6 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 14.1% · Q4 11.4% · 4Q avg 7.8% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
12.0%
2.9 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.5% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.1% |
1.5%
1.4 pts better
|
1.6%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
88.0%
10.4 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| 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 25.0% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-14 · Fire 2023-09-14
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-08-11 · Fire 2022-08-11
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-09-14
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-10-14
C · Minimal harm
2023-09-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-31
D · Potential for more than minimal harm
2022-08-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-11
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-09-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-09-19
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 2024-10-19
E · Potential for more than minimal harm
2024-09-19
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 2024-10-19
E · Potential for more than minimal harm
2024-09-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-19
D · Potential for more than minimal harm
2024-09-19
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 2024-10-19
D · Potential for more than minimal harm
2024-09-19
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 2024-10-19
D · Potential for more than minimal harm
2024-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-19
E · Potential for more than minimal harm
2023-09-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-14
E · Potential for more than minimal harm
2023-09-14
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 2023-10-14
E · Potential for more than minimal harm
2023-09-14
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 2023-10-14
D · Potential for more than minimal harm
2023-09-14
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 2023-10-14
D · Potential for more than minimal harm
2023-09-14
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 2023-10-14
D · Potential for more than minimal harm
2023-09-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-14
E · Potential for more than minimal harm
2022-08-11
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-11
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-11
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-11
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 2022-09-16
D · Potential for more than minimal harm
2022-08-11
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 2022-09-16
Penalties and ownership
What sits behind the stars
Ownership
The Legacy Willow Bend, Inc.
5% Or Greater Direct Ownership Interest · Organization
Snorton, Scott
Corporate Officer · Individual
Stansbury, Deanna
Operational/Managerial Control · Individual
The Legacy Senior Communities Inc
Operational/Managerial Control · Organization
Walshe, Bridgette
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Stonemere Rehabilitation Center
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4-star overall rating with 4-star inspections with 5 recent health deficiencies
#2
Accel At Willow Bend
Plano, TX
2-star overall rating with 2-star inspections with $64,588 in total fines with 18 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Prestonwood Rehabilitation & Nursing Center Inc
Plano, TX
3-star overall rating with 2-star inspections with abuse icon flag with $14,433 in total fines with 9 recent health deficiencies
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