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Legend Oaks Healthcare and Rehabilitation - Waxaha
151 Country Meadows Boulevard, Waxahachie, TX 75165 · CMS Certification Number (CCN) 676421
At a glance
- CMS overall rating
- ★☆☆☆☆ 1 of 5
- Health inspection citations
- 36 in the last 3 inspection cycles (2 immediate jeopardy, 3 actual harm, 20 from complaints)
- Fire safety citations
- 1
- Fines (last 3 years)
- 3 fines, total $41,215
- Payment denials
- 0
- Most recent standard inspection
- February 12, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★☆☆☆☆ 1 of 5 | 2.7 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★☆☆ 3 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
| Short-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | February 12, 2026 | 10 | 5 | 5 |
| Cycle 2 | November 15, 2024 | 21 | 9 | 15 |
CMS weighted health inspection score: 111.5 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
36 health citations across 13 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
July 25, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/14/2026 |
April 15, 2026: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/17/2026 |
| E | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/17/2026 |
February 12, 2026: 5 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0850 | Hire a qualified full-time social worker in a facility with more than 120 beds. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/16/2026 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/16/2026 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/16/2026 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/16/2026 |
| D | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/16/2026 |
December 12, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/15/2025 |
November 24, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/01/2025 |
April 14, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/12/2025 |
November 15, 2024: 9 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/10/2024 |
| D | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/10/2024 |
| D | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/10/2024 |
| G | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/10/2024 |
| G | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/10/2024 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/10/2024 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/10/2024 |
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/10/2024 |
| D | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/10/2024 |
June 17, 2024: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/18/2024 |
| D | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/18/2024 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/18/2024 |
March 7, 2024: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/08/2024 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/29/2024 |
February 7, 2024: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/04/2024 |
| G | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/04/2024 |
January 23, 2024: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0761 | 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. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/07/2024 |
| D | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/07/2024 |
| D | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/07/2024 |
October 5, 2023: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies | Complaint | Past Non-Compliance Corrected 09/29/2023 |
September 13, 2023: 5 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/06/2023 |
| D | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/06/2023 |
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/06/2023 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/06/2023 |
| D | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/06/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Fire safety inspections
1 fire safety citations across 1 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 09/13/2023 | E | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 02/21/2024 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| November 15, 2024 | Fine | $11,466 | — |
| March 7, 2024 | Fine | $15,851 | — |
| January 23, 2024 | Fine | $13,898 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.55 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.25 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 1.08 | Not published | Not published |
| Nurse aide hours per resident per day | 2.22 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.87 | Not published | Not published |
| RN hours per resident per day, weekends | 0.21 | Not published | Not published |
| Total nursing staff turnover (%) | 57.6 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 37.5 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Facility details
- Legal business name
- Eastland Memorial Hospital District
- Ownership type
- For profit - Individual
- Chain
- The Ensign Group (344 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 121
- Average residents per day
- 101.7
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Both
- First approved for Medicare/Medicaid
- January 31, 2017
- County/parish
- Ellis
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Owners and managers reported to CMS
15 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| EASTLAND MEMORIAL HOSPITAL DISTRICT | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| MUNIZ, FELICIA | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| VASSA, NEAL | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BURNAM, SOON | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KEETCH, CHAD | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| TAYLOR, STEPHEN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| COW CREEK HEALTHCARE, INC. | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MUNIZ, FELICIA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| VASSA, NEAL | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| COW CREEK HEALTHCARE, INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ENSIGN SERVICES INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| NATIONAL HEALTH INVESTORS, INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| TEXAS NHI INVESTORS, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MUNIZ, FELICIA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| VASSA, NEAL | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Check it yourself
- Medicare Care Compare: Legend Oaks Healthcare and Rehabilitation - Waxaha. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 25, 2026. Not a ranking or endorsement.