Legend Oaks Healthcare and Rehabilitation - Fort W
4240 Golden Triangle Boulevard, Keller, TX 76244 · Tarrant County · 132 certified beds · avg 107 residents/day · certified since Jun 1, 2017
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Jun 13, 2026 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jun 14, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Sep 11, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 29, 2025 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Oct 8, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 23, 2024 (Past Non-Compliance)
▲ Actual harm, repeated · Apr 17, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Apr 27, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 26, 2026 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 22, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 26, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 30, 2025 (Past Non-Compliance)
All citations in the current public record (26)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 30, 2026 | D · Potential for harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Jun 23, 2026 | E · Potential for harm, repeated | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. · from a complaint |
| Jun 13, 2026 | ▲ K · Immediate jeopardy, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Apr 17, 2026 | ▲ H · Actual harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 26, 2026 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Mar 5, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 5, 2026 | E · Potential for harm, repeated | The facility did not dispose of garbage and refuse properly. |
| Mar 5, 2026 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Mar 5, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 5, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Mar 5, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Mar 5, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Sep 11, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 26, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Oct 8, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 8, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · from a complaint |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | E |
| 2024 | 7 | 1 | J ▲ |
| 2025 | 2 | 2 | J ▲ |
| 2026 | 12 | 3 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
6 fines totaling $77,433.
| Date | Type | Amount / length |
|---|---|---|
| Jun 13, 2026 | Fine | $11,850 |
| Mar 5, 2026 | Fine | $18,150 |
| Mar 5, 2026 | Fine | $19,135 |
| Sep 11, 2025 | Fine | $10,361 |
| Feb 26, 2025 | Fine | $9,110 |
| Oct 8, 2024 | Fine | $8,827 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.06 | 3.46 | 3.95 | bottom 26% in Texas; bottom 16% in the U.S. |
| Registered Nurse hours | 0.48 | 0.44 | 0.69 | top 29% in Texas; bottom 35% in the U.S. |
| Weekend total nurse staffing | 2.66 | 3.04 | 3.50 | bottom 27% in Texas; bottom 15% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.34 | 0.34 | 0.48 | top 37% in Texas; bottom 40% in the U.S. |
| Total nursing staff turnover (%) | 67.8 | 55.3 | 45.8 | bottom 21% in Texas; bottom 8% in the U.S. |
| RN turnover (%) | 62.5 | 54.6 | 42.9 | bottom 38% in Texas; bottom 19% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.13, RN 0.49, weekend 2.72. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Eastland Memorial Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/2019 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 03/02/2016 |
| Cantrell, Christopher | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2017 |
| Cantrell, Christopher | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2017 |
| Cantrell, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2017 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2017 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| National Health Investors, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2017 |
| NB Brown Rock Healthcare, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2019 |
| NB Brown Rock Healthcare, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2025 |
| Porter, Kris | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/23/2023 |
| Porter, Kris | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/23/2023 |
| Porter, Kris | Individual | ADP of the SNF | NOT APPLICABLE | 10/23/2023 |
| Taylor, Stephen | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2025 |
| Texas Nhi Investors, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
- "What are your rules for bringing in my family member's favorite foods, and how are they stored?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can I see where garbage is stored and how often it's removed?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| The Harrison at Heritage | 1.2 mi | Fort Worth, TX | ★★★☆☆ | 2/5 | |
| Heritage House at Keller Rehab & Nursing | 2.6 mi | Keller, TX | ★★★★★ | 4/5 | |
| Green Valley Healthcare and Rehabilitation Center | 5.1 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | |
| North Pointe Nursing and Rehabilitation | 5.3 mi | Watauga, TX | ★☆☆☆☆ | 1/5 | |
| Discovery Village at Southlake | 5.5 mi | Southlake, TX | ★★★★★ | 5/5 | |
| The Carlyle at Stonebridge Park | 5.9 mi | Southlake, TX | ★☆☆☆☆ | 2/5 | |
| Keller Oaks Healthcare Center | 6.1 mi | Keller, TX | ★★★★☆ | 4/5 | |
| The Lodge of Saginaw Health and Wellness | 7.1 mi | Saginaw, TX | ★★★☆☆ | 3/5 | |
| Avir at Emerald Hills | 7.2 mi | North Richland Hills, TX | ★★☆☆☆ | 2/5 | |
| Oakmont Guest Care Center | 7.9 mi | Hurst, TX | ★☆☆☆☆ | 1/5 | |
| Glenview Wellness & Rehabilitation | 8.7 mi | North Richland Hills, TX | ★☆☆☆☆ | 2/5 | |
| Richland Hills Rehabilitation and Healthcare Cente | 9.2 mi | Fort Worth, TX | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676426.