For profit - Individual · 121 certified beds · CMS number 676421
Legend Oaks Healthcare and Rehabilitation - Waxaha, Waxahachie, TX
CMS records 36 health deficiencies at Legend Oaks Healthcare and Rehabilitation - Waxaha in Waxahachie, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Feb 12, 2026. The highest severity cited is J (immediate jeopardy to resident health or safety). 2 citations were at the immediate jeopardy level. CMS lists 3 fines totaling $41,215 in the last three years.
- 36deficiencies, 3 cycles (TX median 25)
- 10in the latest cycle (TX median 8)
- Jhighest severity · Immediate jeopardy
- $41,215fines, last 3 years
- 1CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Legend Oaks Healthcare and Rehabilitation - Waxaha as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Legend Oaks Healthcare and Rehabilitation - Waxaha may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (10 deficiencies)
Standard inspection Feb 12, 2026. CMS counts 10 health deficiencies and 0 fire safety deficiencies in this cycle.
Jul 25, 2026 · Complaint inspection
1 deficiency, highest D
F644 · Coordinating with PASARR screening
Requirement cited (CMS): Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 14, 2026
Apr 15, 2026 · Complaint inspection
2 deficiencies, highest E
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 17, 2026
F580 · Telling residents and families about changes
Requirement cited (CMS): Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 17, 2026
Feb 12, 2026 · Standard inspection
5 deficiencies, highest E
F850 · Full-time social worker in larger homes
Requirement cited (CMS): Hire a qualified full-time social worker in a facility with more than 120 beds.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 16, 2026
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 16, 2026
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 16, 2026
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 16, 2026
F645 · Pre-admission screening for mental disorder or intellectual disability
Requirement cited (CMS): PASARR screening for Mental disorders or Intellectual Disabilities
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 16, 2026
Dec 12, 2025 · Complaint inspection
1 deficiency, highest D
F842 · Complete, confidential medical records
Requirement cited (CMS): Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 15, 2025
Nov 24, 2025 · Complaint inspection
1 deficiency, highest D
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 1, 2025
Previous cycle: 10 deficiencies (standard inspection Nov 15, 2024)
Standard inspection Nov 15, 2024. CMS counts 10 health deficiencies and 0 fire safety deficiencies in this cycle.
Apr 14, 2025 · Complaint inspection
1 deficiency, highest D
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 12, 2025
Nov 15, 2024 · Standard + complaint inspection
9 deficiencies, highest G
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 10, 2024
F804 · Palatable, attractive food at safe temperatures
Requirement cited (CMS): Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 10, 2024
F757 · Avoiding unnecessary drugs
Requirement cited (CMS): Ensure each resident’s drug regimen must be free from unnecessary drugs.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 10, 2024
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- G Actual harm (not immediate jeopardy), isolated
- Status
- Correction date Dec 10, 2024
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- G Actual harm (not immediate jeopardy), isolated
- Status
- Correction date Dec 10, 2024
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 10, 2024
F641 · Accurate resident assessments
Requirement cited (CMS): Ensure each resident receives an accurate assessment.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 10, 2024
F609 · Reporting suspected abuse and crimes
Requirement cited (CMS): Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 10, 2024
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 10, 2024
Earlier cycle: 16 deficiencies (standard inspection Sep 13, 2023)
Standard inspection Sep 13, 2023. CMS counts 16 health deficiencies and 1 fire safety deficiency in this cycle.
Jun 17, 2024 · Complaint inspection
3 deficiencies, highest D
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 18, 2024
F584 · Safe, clean, homelike surroundings
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 18, 2024
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 18, 2024
Mar 7, 2024 · Complaint inspection
2 deficiencies, highest J
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Mar 8, 2024
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 29, 2024
Feb 7, 2024 · Complaint inspection
2 deficiencies, highest J
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Mar 4, 2024
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- G Actual harm (not immediate jeopardy), isolated
- Status
- Correction date Mar 4, 2024
Jan 23, 2024 · Complaint inspection
3 deficiencies, highest E
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 7, 2024
F686 · Pressure ulcer prevention and care
Requirement cited (CMS): Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 7, 2024
F580 · Telling residents and families about changes
Requirement cited (CMS): Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 7, 2024
Oct 5, 2023 · Complaint inspection
1 deficiency, highest D
F693 · Feeding tube use and care
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Past non-compliance (fixed before the inspection), Sep 29, 2023
Sep 13, 2023 · Standard inspection
5 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 6, 2023
F760 · No significant medication errors
Requirement cited (CMS): Ensure that residents are free from significant medication errors.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 6, 2023
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 6, 2023
F677 · Help with daily care
Requirement cited (CMS): Provide care and assistance to perform activities of daily living for any resident who is unable.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 6, 2023
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 6, 2023
Tags cited in more than one inspection
9 tags cited on more than one inspection date at Legend Oaks Healthcare and Rehabilitation - Waxaha; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F656 Comprehensive person-centered care plan | 3 | Apr 14, 2025; Nov 15, 2024; Mar 7, 2024 |
| F684 Quality of care | 3 | Apr 15, 2026; Nov 15, 2024; Feb 7, 2024 |
| F689 Accident prevention and supervision | 3 | Nov 15, 2024; Mar 7, 2024; Feb 7, 2024 |
| F550 Dignity and the right to exercise rights | 2 | Nov 24, 2025; Jun 17, 2024 |
| F558 Accommodating individual needs and preferences | 2 | Nov 15, 2024; Sep 13, 2023 |
| F580 Telling residents and families about changes | 2 | Apr 15, 2026; Jan 23, 2024 |
| F755 Pharmacy services and a consultant pharmacist | 2 | Feb 12, 2026; Jun 17, 2024 |
| F761 Drug labeling and secure storage | 2 | Feb 12, 2026; Jan 23, 2024 |
| F880 Infection prevention and control program | 2 | Nov 15, 2024; Sep 13, 2023 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| Nov 15, 2024 | Fine | $11,466 |
| Mar 7, 2024 | Fine | $15,851 |
| Jan 23, 2024 | Fine | $13,898 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 3.55 h (above the Texas median of 3.27 h)
- RN hours per resident per day
- 0.25 h (below the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 2.87 h
- Nursing staff turnover
- 57.6% (Texas median 52.1%)
- Administrators who left
- 0
- CMS overall rating
- 1 of 5
- Health inspection rating
- 2 of 5
- Staffing rating
- 1 of 5
- Quality measure rating
- 3 of 5
CMS figures for Legend Oaks Healthcare and Rehabilitation - Waxaha, copied as published; Texas medians are ours.
Facility details
- Address
- 151 Country Meadows Boulevard, Waxahachie, TX 75165
- Phone
- (972) 937-1650
- County
- Ellis
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Individual
- Chain (CMS)
- The Ensign Group
- Certified beds
- 121
- Average residents per day
- 101.7
- In Medicare/Medicaid since
- Jan 31, 2017
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Both
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How are a resident's goals and preferences written into the care plan? (F656, cited 3 times)
- How does the home make sure doctor's orders are followed consistently across shifts? (F684, cited 3 times)
- How does the home assess each resident's fall risk and plan to prevent falls? (F689, cited 3 times)
- How do staff learn about and respect each resident's personal routines and choices? (F550, cited 2 times)
Other nursing homes in Waxahachie and the same chain
- Focused Care of Waxahachie
Waxahachie · 37 deficiencies - Pleasant Manor Healthcare and Rehabilitation
Waxahachie · 29 deficiencies - The Eden of Las Colinas
Irving · 65 deficiencies - Northeast Rehabilitation and Healthcare Center
San Antonio · 57 deficiencies - Westpark Rehabilitation and Living
Euless · 54 deficiencies - Park Village Healthcare and Rehabilitation
DeSoto · 52 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.