Legend Oaks Healthcare And Rehabilitation - Waxaha

Location & what’s nearby

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

48.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 219 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 57.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 80 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.97 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 121 beds and averages 101.7 residents a day — about 84% occupied, or roughly 19 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.87 hrs/resident/day on weekends vs 3.82 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.26 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

35 citations, most serious first. The 15 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-03-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision for one (Resident #1) of five residents reviewed for accidents and hazards, in that: The facility failed to assist and monitor Resident #1 during meal service on 02/20/24 when she was served dinner despite a hospice order dated 02/11/24 stating that she should be assisted with meals and not left alone with food, and Resident #1 choked and was subsequently sent to the ER where she was diagnosed with aspiration pneumonia and remained hospitalized until 02/25/24. An Immediate Jeopardy (IJ) was identified on 03/05/24. While the IJ was removed on 03/06/24, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of choking, aspiration…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-02-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 18 Residents (Resident #1 and Resident #2) reviewed for accidents and hazards. 1. The facility failed to ensure Resident #1 received microwaved food, from an outside source, at a temperature for safe elderly consumption which resulted in a second-degree burn. 2. The facility failed to ensure Resident # 2 had total assistance while consuming a cup of hot coffee resulting in medical attention for skin irritation. On 2-5-2024 at 7:54 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 2-7-2024 at 2:40 PM, the facility remained out of compliance at a scope of isolated with a severity level of potential of more than minimal harm, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: 1. Record review of the facilities investigation report, dated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 9 Residents (Resident #162) reviewed for quality of care. The facility failed to ensure Resident #162 made follow up appointment with a wound care specialist. This failure placed residents at risk of condition exacerbation, psychosocial harm, and infection. Findings included: Record review of an intake, dated 11/7/2024 at 8:21 AM, reflected a complaint made by a responsible party on behalf of Resident #162. The intake alleged on 11/2/2024 a staff attempted to transfer Resident #162 from her wheelchair to her bed. The complainant alleged Resident #162 required 2 people to transfer her, but only 1 staff member was present. The complainant alleged Resident #162 received a wound, a huge gash to her leg. Resident #162 was rushed to the hospital where she received a blood transfusion. Upon her release, Resident #162 was supposed to have…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents' environments remained as free from accident hazards as possible for 1 of 9 Residents (Resident #162) reviewed for environmental accidents. The facility failed to ensure Resident #162 was free from environmental hazards and accidents during a 1 person transfer from a wheelchair to a bed. This failure placed residents at risk of physical and psychosocial harm. Findings included: Record review of an intake, dated 11/7/2024 at 8:21 AM, reflected a complaint made by a responsible party on behalf of Resident #162. The intake alleged on 11/2/2024 a staff attempted to transfer Resident #162 from her wheelchair to her bed. The complainant alleged Resident #162 required 2 people to transfer her, but only 1 staff member was present. The complainant alleged Resident #162 received a wound, a huge gash to her leg. Resident #162 was rushed to the hospital where she received a blood transfusion. Upon her release, Resident #162 was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents received treatment and care with professional standards of practice for 1 of 19 Residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 received immediate medical care after he spilled a bowl of [steaming] soup on his right lower torso area, which caused a 2nd degree burn. The incident went unreported and undetected for 1 calendar day. This failure placed residents at the facility at risk for unmet medical attention. Findings included: Record review of the facilities investigation report, dated 1-24-2024, indicated Resident #1 asked CNA A for assistance with heating up a bowl of soup on 1-16-2024. CNA A heated the soup and returned it to Resident #1 on his bedside table. Resident #1 accidently knocked the soup from the bedside table onto his right lower torso area having yelled out in pain. CNA A returned shortly to render aid, where she cleaned him, and provided clean linen and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-04-15 · tag F0580 — failed to tell family and doctor about changes — pattern
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident's representative of the significant change in the resident's physical, mental, or psychosocial status for two residents (Resident #2 and Resident #3) of ten residents reviewed for resident rights. The facility failed to inform Resident #2's RP she was being transferred to another facility on 3/7/2026. The facility failed to ensure Resident #3's RP was notified when she fell on 3/17/2026 or 3/18/2026. The facility failed to ensure Resident #3's Physician was notified when she fell on 3/17/2026 or 3/18/2026. This failure placed residents at risk of a decreased quality of life and risk of not having their responsible party represent them in medical and care decisions or having their Physician make care decisions post fall. Findings included:Resident #2Review of Resident #2's face sheet dated 4/8/2026, reflected a [AGE] year-old female admitted to the facility on [DATE], with…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-04-15 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one 1 (Resident #1) of ten residents reviewed for quality of care. The facility failed to remove Resident #1's PICC line before he discharged on 3/12/2026. Nurse E failed to report a fall for Resident #3 on or about 3/17/2026 or 3/18/2026. Nurse E failed to assess Resident #3 for injuries after a fall on or about 3/17/2026 or 3/18/2026 These failures placed Resident at risk of injury, infection, not receiving adequate care and services, and decreased quality of life.Findings include: Review of Resident #1's face sheet dated 4/8/2026, reflected a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included: cellulitis of right lower limb (bacterial skin infection) , cellulitis of left lower limb, muscle weakness, hypertension (high blood pressure), atrial fibrillation (heart rhythm disorder), chronic heart failure (chronic…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.The facility failed to ensure food was properly labeled and dated.This deficient practice could place residents who ate food served from the kitchen at risk for health complications and foodborne illnesses.Findings included:An observation on 02/10/2026 at 9:18 AM in the facility's walk-in cooler revealed 1 large plastic container of mayonnaise, 1 container of white meat chicken salad with cranberries and pecans, and 1 container of chopped dilled relish that was not labeled or dated. In an interview on 02/12/2026 at 12:33 PM, KW A stated he was trained on labeling and dating recently and that all food should be labeled and dated after they were opened, and if this was not done then residents could become sick.In an interview on 02/12/2026 at 12:41 PM, KW B stated she had been in-serviced recently on food labeling and dating and it should be done on every item that was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-12 · tag F0850 — failed to provide social-work services — pattern
  Hire a qualified full-time social worker in a facility with more than 120 beds.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis for 1 of 1 facility's reviewed for qualifications of a Social Worker. The facility, licensed for 121 beds, did not employ a full-time, qualified social worker. This failure could place residents at risk for unmet social services and psychosocial needs. Findings included: Review of the Facility Summary Report from the Texas Unified Licensure Information Portal (TULIP) dated 02/10/2026 reflected the facility had a total licensed capacity of 121 beds. Review of the Key Staff Roster, undated, provided by the ADM on 02/10/2026 to the state surveyor, revealed no personnel named next to the job title Social Services Director. In an interview on 02/12/2026 at 11:14 AM with the ADM, she stated that the facility had been without a qualified social worker since the last week of January 2026. She stated that they had an assistant social worker currently employed, but that individual was not licensed nor had the educational requirements for a nursing…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0645 — isolated
  PASARR screening for Mental disorders or Intellectual Disabilities
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the proper coordination of PASARR assessments for 1 (Resident #41) of 7 residents reviewed for PASARR screenings and evaluations. The facility failed to refer Resident #41 for a PASARR Level II evaluation despite her PASARR Level 1 indicated a diagnosis of MI. This failure could place residents with no PASARR Level II Evaluation at risk of not receiving specialized care and services to meet their needs or obtain their highest practicable well-being.Findings included: Review of Resident #41's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses: aphasia (communication disorder caused by damage to the brain that affects a person's ability to speak, understand, read, or write), malnutrition (imbalance in a person's intake of energy and nutrients, affecting overall health and development), bipolar disorder (extreme mood swings that affects the ability to think…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-12 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish a system of accurate reconciliation and removal of expired/discontinued medications from nursing med carts for 1 (500-hall med cart) of 4 med carts reviewed for pharmacy services and medication storage. The 500-hall nursing medication cart had a box of lubricant eye drops labeled for Resident #13 with an expiration date of 01/2026. The 500-hall nursing medication cart had two boxes of wound dressing with antibacterial silver with an expiration date of 07/01/2025. These failures had the potential risk of affecting 24 residents on 500-hall receiving medications from 500-hall med cart which could place them at risk for having non-therapeutic levels of medications and delayed healing.Findings included: In an observation on 2/11/2026 at 9:58 a.m. the 500-hall's nursing medication cart revealed a box with lubricant eye drops (for temporary relief from dry, burning, and irritated eyes) labeled for Resident #13 with an expiration date of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-12 · tag F0761 — failed to label and store drugs safely — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the open date for insulin for 1 (300-hall med cart) of 4 med carts reviewed for medication storage. The 300-hall nursing medication cart had an insulin pen labeled for Resident #39 and was not labeled with an open date. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of their medications and a decline in health status.Findings included: In an observation on 2/11/2026 at 10:18 a.m., the 300-hall nursing medication cart revealed an insulin pen with 100 units/ml for Resident #39 without open date information available. Record review of Resident #39's face sheet, dated 2/12/2026, revealed a 79-years-old male admitted on [DATE] and readmitted on [DATE]. Resident's #39's diagnoses included type 2 diabetes Mellitus (a chronic metabolic disorder characterized…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-12 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) for resident records. The facility failed to ensure Resident #1's medication and treatment was documented in PCC for 12/06/2025, 12/09/2025 and 12/11/2025.This failure could place residents at risk for the possibility of not verifying the needed care and services to meet their needs. Findings included:A record review of Resident #1's face sheet, dated 12/12/2025, reflected an [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included type 2 diabetes (body does not make enough insulin), muscle weakness (loss of muscle strength), hypertension (high blood pressure), and congestive heart failure (heart muscle weakens or stiffing failing to pump enough oxygen to meet the body's needs).A record review of Resident #1's care plan, dated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-24 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure residents were afforded rights, including the right to self-determination, for 1 of 6 residents (Resident #1) reviewed for resident rights.The facility failed to ensure Resident #1's Statutory Durable Power of Attorney (DPOA) was appropriately executed in that its elected agents and witness were facility staff, which posed a conflict of interest and the potential for impropriety, and it was implemented during a time in which the resident's capacity to consent was in question. This failure created a dual relationship between the resident and staff and a conflict of interest which could have placed the resident at risk of harm, fraud, exploitation, and/or other legal and medical complications.Findings include:Record review of Resident #1's face sheet revealed a [AGE] year-old male whose most recent admission to the facility was on [DATE], with an initial admission date of [DATE], and an original admission date of [DATE]. The other…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-14 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of 5 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated to reflect the resident no longer being treated for a yeast infection. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings Included: Review of Resident #1's face sheet dated 04/14/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included essential primary hypertension(a condition characterized by persistently elevated blood pressure without an identifiable underlying cause), unspecified dementia( where the underlying cause or specific type of dementia is not determined ,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$41,215 in federal fines across 3 penalties.

• $11,466 — penalty dated 2024-11-15
• $15,851 — penalty dated 2024-03-07
• $13,898 — penalty dated 2024-01-23

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX