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TheVardellReport
Legend Oaks Healthcare and Rehabilitation - Waxaha
Skilled nursing facility and nursing facility
151 Country Meadows Boulevard
Waxahachie, TX 75165
Report
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The Vardell Report.Legend Oaks Healthcare and Rehabilitation - Waxaha
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Waxahachie, TX
- Record Period
- 2023–2026
- Source Documents
- 15
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 13 inspections from September 2023 to July 2026, state surveyors documented 36 findings at Legend Oaks Healthcare and Rehabilitation - Waxaha; 36 have a recorded correction; CMS lists 3 enforcement actions in the window.
- Inspections
- 13
- 2023–2026, complaint and standard
- Findings
- 36
- Deficiencies cited by state inspectors
- Corrected
- 36
- Of 36 findings, with a recorded correction date
- Penalties
- 3
- 3 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 2 | 6 | 0 |
| 2024 | 5 | 19 | 5 |
| 2025 | 3 | 3 | 0 |
| 2026 | 3 | 8 | 0 |
What the Record Shows
- 36 of 36 findings have a recorded correction date.
- CMS lists 3 enforcement actions in the window: 3 fines totaling $41,215, their payment not published.
- 11 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, February 12, 2026, recorded 5 findings (most serious: Level E).
What to Ask About
- Care Plans, Cited in Three Inspections
- Quality of Care, Cited in Three Inspections
- Accident Hazards and Supervision, Cited in Three Inspections
- Dignity and Resident Rights, Cited in Two Inspections
- Needs and Preferences, Cited in Two Inspections
- Telling Families About Changes, Cited in Two Inspections
- Pharmacy Services, Cited in Two Inspections
- Medication Labeling and Storage, Cited in Two Inspections
- Infection Control, Cited in Two Inspections
Report at a Glance
- Facility
- Legend Oaks Healthcare and Rehabilitation - Waxaha
- Address
- 151 Country Meadows Boulevard, Waxahachie, TX 75165
- CMS Certification Number
- 676421
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 121
- Ownership
- For profit - Individual
- Record Window
- September 13, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
1 finding
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Aug 14, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
2 findings
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level ENo actual harm, potential for moreCorrected Apr 17, 2026
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Apr 17, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Standard health inspection
5 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Mar 16, 2026
- F850Hire a qualified full-time social worker in a facility with more than 120 beds.Level ENo actual harm, potential for moreCorrected Mar 16, 2026
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Mar 16, 2026
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Mar 16, 2026
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Mar 16, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Dec 15, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Dec 1, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected May 12, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
9 findings
The same visit included a complaint investigation.
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Dec 10, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Dec 10, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Dec 10, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Dec 10, 2024
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Dec 10, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Dec 10, 2024
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Dec 10, 2024
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Dec 10, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Dec 10, 2024
Enforcement Action
Civil money penalty, $11,466 imposed November 15, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 15, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
3 findings
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jun 18, 2024
- F584Honor 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.Level DNo actual harm, potential for moreCorrected Jun 18, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jun 18, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Mar 8, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 29, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Mar 4, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Mar 4, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
3 findings
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Feb 7, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Feb 7, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Feb 7, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
1 finding
- F693Ensure 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.Level DNo actual harm, potential for moreCorrected Sep 29, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
5 findings
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Oct 6, 2023
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Oct 6, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 6, 2023
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Oct 6, 2023
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Oct 6, 2023
Enforcement Action
Civil money penalty, $13,898 imposed January 23, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 13, 2023, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $15,851 imposed March 7, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 13, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Care Plans, Cited in Three Inspections
Inspectors cited F656 in March 2024, November 2024 and April 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242424252525262626F656 across all 13 inspections, oldest to newest - 2
Quality of Care, Cited in Three Inspections
Inspectors cited F684 in February 2024, November 2024 and April 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242424252525262626F684 across all 13 inspections, oldest to newest - 3
Accident Hazards and Supervision, Cited in Three Inspections
Inspectors cited F689 in February 2024, March 2024 and November 2024. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242424252525262626F689 across all 13 inspections, oldest to newest - 4
Dignity and Resident Rights, Cited in Two Inspections
Inspectors cited F550 in June 2024 and November 2025. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242424252525262626F550 across all 13 inspections, oldest to newest - 5
Needs and Preferences, Cited in Two Inspections
Inspectors cited F558 in September 2023 and November 2024. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242424252525262626F558 across all 13 inspections, oldest to newest - 6
Telling Families About Changes, Cited in Two Inspections
Inspectors cited F580 in January 2024 and April 2026. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242424252525262626F580 across all 13 inspections, oldest to newest - 7
Pharmacy Services, Cited in Two Inspections
Inspectors cited F755 in June 2024 and February 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242424252525262626F755 across all 13 inspections, oldest to newest - 8
Medication Labeling and Storage, Cited in Two Inspections
Inspectors cited F761 in January 2024 and February 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242424252525262626F761 across all 13 inspections, oldest to newest - 9
Infection Control, Cited in Two Inspections
Inspectors cited F880 in September 2023 and November 2024. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242424252525262626F880 across all 13 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in three inspections, most seriously at level D.
- 02
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in three inspections, most seriously at level G.
- 03
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in three inspections, most seriously at level J.
- 04
How do staff learn each resident’s preferences, and how is a complaint about dignity handled?
Dignity and Resident Rights: cited in two inspections, most seriously at level D.
- 05
How do you adjust rooms, schedules and routines to a resident’s needs and preferences?
Needs and Preferences: cited in two inspections, most seriously at level D.
- 06
How quickly will we hear about a fall, an injury or a change in condition, and from whom?
Telling Families About Changes: cited in two inspections, most seriously at level E.
- 07
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level D.
- 08
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level E.
- 09
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level E.
- 10
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 11
What led to the 2024 fine, and has it been paid?
An $11,466 civil money penalty was imposed November 15, 2024. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Texas state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Sep 13, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Oct 5, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jan 23, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Feb 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Mar 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jun 17, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Nov 15, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Apr 14, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Nov 24, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Dec 12, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Feb 12, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Apr 15, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jul 25, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 676421
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowSeptember 13, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before September 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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