Legend Oaks Healthcare and Rehabilitation - Waxaha
151 Country Meadows Boulevard, Waxahachie, TX 75165 · Ellis County · 121 certified beds · avg 102 residents/day · certified since Jan 31, 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: ★★☆☆☆2/5 · 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, one-off · Mar 7, 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: Mar 8, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 7, 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: Mar 4, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 15, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
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: Dec 10, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 15, 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 10, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 7, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
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: Mar 4, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (35)
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 |
|---|---|---|
| Apr 15, 2026 | E · Potential for harm, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Apr 15, 2026 | E · Potential for harm, repeated | 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 |
| Feb 12, 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. |
| Feb 12, 2026 | E · Potential for harm, repeated | The facility has more than 120 beds but did not hire a qualified full-time social worker as required. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Feb 12, 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. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Dec 12, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Nov 24, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Apr 14, 2025 | 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. · from a complaint |
| Nov 15, 2024 | ▲ G · Actual 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 |
| Nov 15, 2024 | ▲ G · Actual harm, 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 |
| Nov 15, 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. |
| Nov 15, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Nov 15, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Nov 15, 2024 | 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. |
| Nov 15, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Nov 15, 2024 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Nov 15, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 17, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jun 17, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Jun 17, 2024 | 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. · from a complaint |
| Mar 7, 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 |
| Mar 7, 2024 | 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. · from a complaint |
| Feb 7, 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 |
| Feb 7, 2024 | ▲ G · Actual 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 |
| Jan 23, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Jan 23, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jan 23, 2024 | D · Potential for 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 |
| Oct 5, 2023 | 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. · from a complaint |
| Sep 13, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 13, 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. |
| Sep 13, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Sep 13, 2023 | 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. |
| Sep 13, 2023 | D · Potential for harm, one-off | 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. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (9 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 0 | E |
| 2024 | 19 | 5 | J ▲ |
| 2025 | 3 | 0 | D |
| 2026 | 7 | 0 | E |
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)
3 fines totaling $41,215.
| Date | Type | Amount / length |
|---|---|---|
| Nov 15, 2024 | Fine | $11,466 |
| Mar 7, 2024 | Fine | $15,851 |
| Jan 23, 2024 | Fine | $13,898 |
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) | 3.40 | 3.46 | 3.95 | top 43% in Texas; bottom 31% in the U.S. |
| Registered Nurse hours | 0.24 | 0.44 | 0.69 | bottom 15% in Texas; bottom 4% in the U.S. |
| Weekend total nurse staffing | 2.75 | 3.04 | 3.50 | bottom 35% in Texas; bottom 18% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.21 | 0.34 | 0.48 | bottom 25% in Texas; bottom 14% in the U.S. |
| Total nursing staff turnover (%) | 57.6 | 55.3 | 45.8 | bottom 38% in Texas; bottom 20% in the U.S. |
| RN turnover (%) | 37.5 | 54.6 | 42.9 | top 26% in Texas; top 42% 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 3.55, RN 0.25, weekend 2.87. 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: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5
Who owns this facility
For profit - Individual
| 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 | 01/31/2017 |
| Cow Creek Healthcare, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2019 |
| Cow Creek Healthcare, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 08/14/2025 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2019 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Muniz, Felicia | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/31/2017 |
| Muniz, Felicia | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/31/2017 |
| Muniz, Felicia | Individual | ADP of the SNF | NOT APPLICABLE | 01/31/2017 |
| National Health Investors, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 04/29/2016 |
| Taylor, Stephen | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2025 |
| Texas Nhi Investors, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/29/2016 |
| Vassa, Neal | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/30/2018 |
| Vassa, Neal | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/30/2018 |
| Vassa, Neal | Individual | ADP of the SNF | NOT APPLICABLE | 05/30/2018 |
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 is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Do you have a full-time social worker on staff, and how would they work with my family member?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "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 |
|---|---|---|---|---|---|
| Focused Care of Waxahachie | 2.8 mi | Waxahachie, TX | ★☆☆☆☆ | 2/5 | abuse |
| Pleasant Manor Healthcare and Rehabilitation | 5.8 mi | Waxahachie, TX | ★★★☆☆ | 2/5 | |
| Red Oak Health and Rehabilitation Center | 7.1 mi | Red Oak, TX | ★★★☆☆ | 4/5 | |
| Midtowne Meadows Health & Rehab | 9.0 mi | Midlothian, TX | ★★★★☆ | 5/5 | |
| Midlothian Healthcare Center | 9.2 mi | Midlothian, TX | ★★★☆☆ | 3/5 | |
| Park Village Healthcare and Rehabilitation | 9.9 mi | Desoto, TX | ★★☆☆☆ | 1/5 | abuse |
| Methodist Transitional Care Center-Desoto LLC | 11.5 mi | Desoto, TX | ★★★☆☆ | 2/5 | |
| Windsor Gardens | 12.0 mi | Lancaster, TX | ★★☆☆☆ | 2/5 | |
| Millbrook Healthcare and Rehabilitation Center | 12.1 mi | Lancaster, TX | ★☆☆☆☆ | 2/5 | |
| Desoto Nursing & Rehabilitation Center | 12.2 mi | Desoto, TX | ★★★☆☆ | 3/5 | |
| Cedar Hill Healthcare Center | 12.3 mi | Cedar Hill, TX | ★★☆☆☆ | 3/5 | |
| Avir at Lancaster | 12.5 mi | Lancaster, TX | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 676421.