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Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
1/5
Health inspection rating (on-site)
inspected Mar 5, 2026
6
Serious findings on record
most recent Jun 13, 2026
$77,433
Fines, last 3 years
3.06
Nurse hours/resident/day (adjusted)
Every record stays on this page.
What health inspectors found (on-site government inspections — the most independent evidence available)
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 quality measures from resident assessments and claims.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, pattern · 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): Immediate jeopardy to resident health or safety was cited. The scope was a pattern: more than a limited occurrence, without being widespread. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jun 14, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, isolated · 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): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jul 29, 2025 (Past Non-Compliance)
▲ Immediate jeopardy, isolated · 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): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Sep 23, 2024 (Past Non-Compliance)
▲ Actual harm, pattern · 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): Actual harm was cited, below immediate jeopardy. The scope was a pattern: more than a limited occurrence, without being widespread. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Apr 27, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Apr 22, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jan 30, 2025 (Past Non-Compliance)
Inspection findings in the public record
Showing the latest 3 of 26 inspection findings. Open the full record below to read every finding.
D · Potential for more than minimal harm, isolated
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 complaintF-0627
E · Potential for more than minimal harm, pattern
The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. · from a complaintF-0813
K · Immediate jeopardy, pattern
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 complaintF-0760
View all 26 inspection findingsShow only the latest 3 findings
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
Date
Severity
What the facility was cited for
Jun 30, 2026
D · Potential for more than minimal harm, isolated
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 · F-0627
Jun 23, 2026
E · Potential for more than minimal harm, pattern
The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. · from a complaint · F-0813
Jun 13, 2026
▲ K · Immediate jeopardy, pattern
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 · F-0760
Apr 17, 2026
▲ H · Actual harm, pattern
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 · F-0689
Mar 26, 2026
▲ G · Actual harm, isolated
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 · F-0686
Mar 5, 2026
E · Potential for more than minimal harm, pattern
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. · F-0812
Mar 5, 2026
E · Potential for more than minimal harm, pattern
The facility did not dispose of garbage and refuse properly. · F-0814
Mar 5, 2026
E · Potential for more than minimal harm, pattern
The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · F-0842
Mar 5, 2026
D · Potential for more than minimal harm, isolated
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. · F-0656
Mar 5, 2026
D · Potential for more than minimal harm, isolated
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. · F-0690
Mar 5, 2026
D · Potential for more than minimal harm, isolated
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. · F-0695
Mar 5, 2026
D · Potential for more than minimal harm, isolated
The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755
Sep 11, 2025
▲ J · Immediate jeopardy, isolated
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 · F-0689
Feb 26, 2025
▲ G · Actual harm, isolated
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 · F-0600
Dec 19, 2024
D · Potential for more than minimal harm, isolated
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. · F-0693
Dec 19, 2024
D · Potential for more than minimal harm, isolated
The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · F-0694
Dec 19, 2024
D · Potential for more than minimal harm, isolated
The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698
Oct 8, 2024
▲ J · Immediate jeopardy, isolated
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 · F-0689
Oct 8, 2024
D · Potential for more than minimal harm, isolated
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 · F-0684
Jun 6, 2024
D · Potential for more than minimal harm, isolated
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 · F-0558
Jun 6, 2024
D · Potential for more than minimal harm, isolated
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 · F-0644
Nov 16, 2023
E · Potential for more than minimal harm, pattern
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. · F-0727
Nov 16, 2023
E · Potential for more than minimal harm, pattern
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. · F-0812
Nov 16, 2023
D · Potential for more than minimal harm, isolated
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. · F-0558
Nov 16, 2023
D · Potential for more than minimal harm, isolated
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. · F-0636
Nov 16, 2023
D · Potential for more than minimal harm, isolated
The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 7).
Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2023
All citations:
5
Serious citations (G–L):
0
2024
All citations:
7
Serious citations (G–L):
1
2025
All citations:
2
Serious citations (G–L):
2
2026
All citations:
12
Serious citations (G–L):
3
All bars start at zero. Exact values and supporting details remain below.
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.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
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)
Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilityTexas averageU.S. average
Total nurse staffing (hours per resident per day)
This facility:
3.06
Texas average:
3.46
U.S. average:
3.95
Registered Nurse hours
This facility:
0.48
Texas average:
0.44
U.S. average:
0.69
Weekend total nurse staffing
This facility:
2.66
Texas average:
3.04
U.S. average:
3.50
All bars start at zero. Exact values and supporting details remain below.
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 for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.13 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 1/5.
Quality measures: assessments & claims
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
No verified facility-specific private-pay price is available in our data for Legend Oaks Healthcare and Rehabilitation - Fort W. CMS inspection and staffing records do not tell us what this home will charge you.
Calculate a stay from a quote you receive
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Before you compare prices
Request the room type, effective date and itemized daily rate in writing.
Ask about therapy, medicines, supplies, care-level charges, deposits, refunds and annual increases.
Confirm insurance or Medicaid eligibility and bed availability directly; certification alone does not guarantee either.
All 15 owning or managing parties CMS has on file are shown — none excluded.
Other facilities in the same chain
CMS lists this facility under the chain The Ensign Group — 342 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
CMS records place this facility in Tarrant, TX — 71 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
Facility data as of CMS processing date 2026-08-01. CCN 676426.
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The Care File
Visit checklist — Legend Oaks Healthcare and Rehabilitation - Fort W
4240 Golden Triangle Boulevard, Keller, TX 76244 · (817) 806-6400
Health inspection rating 1/5 · CMS overall 1/5· Fines (3y): $77,433
Most serious findings on record:
▲ Jun 13, 2026 (F-0760, Immediate jeopardy, pattern): 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.
▲ Sep 11, 2025 (F-0689, Immediate jeopardy, isolated): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ Oct 8, 2024 (F-0689, Immediate jeopardy, isolated): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Questions for the administrator:
☐ "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?"
☐ "Your weekend nurse staffing is reported below the Texas midpoint — how does the weekend schedule differ from a weekday?"
☐ "Can I see the plan of correction for the findings in your most recent state inspection?"
☐ "CMS reports 68% total nursing staff turnover here — who on the care team has been with you longest?"
☐ "The ownership record on file lists 15 owning or managing parties — who makes the decisions about staffing levels?"
☐ "Can I visit again unannounced, at a mealtime or on a weekend?"
While you're there, notice:
☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)
Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 676426 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)