Legend Oaks Healthcare And Rehabilitation Waxahachie in Waxahachie, Ellis County, Texas

Waxahachie, Ellis County, Texas 75165

Status Medicare and Medicaid certifiedMedicare CCN 676421

HHSC license rosteras of November 9, 2026CMS nursing home filerelease October 28, 2026; processing date October 1, 2026CMS processing date for this home October 1, 2026

Verify on TULIP View on Medicare.gov

Location and contact

Address: 151 Country Meadows Boulevard
Waxahachie, TX 75165
Open map (OpenStreetMap)
Phone: (972) 937-1650
HHSC facility ID: 106645
License number: 307208

Medicare ratings

Star ratings below are copied from the CMS Provider Information file (official release October 28, 2026; processing date October 1, 2026). They are not assigned by NursingCareLookup. See how to read ratings and CMS Five-Star documentation.

Overall: 1 of 5Overall: 1 of 5 stars
Health inspection: 2 of 5Health inspection: 2 of 5 stars
Staffing: 1 of 5Staffing: 1 of 5 stars
Quality measures: 4 of 5Quality measures: 4 of 5 stars
Long-stay quality measures: 4 of 5Long-stay quality measures: 4 of 5 stars
Short-stay quality measures: 3 of 5Short-stay quality measures: 3 of 5 stars

Staffing hours

Hours are the facility’s reported nurse staffing hours per resident per day from the CMS file. The Texas average is computed on this site from Texas rows in that same file that include a numeric value. It is not copied from another website. Method: Methodology.

Staffing hours per resident per day
Measure	This facility	Texas average (this site)
Total nurse staffing	3.59 hours	3.42 hours n=1,152
Registered nurse	0.25 hours	0.44 hours
LPN	1.02 hours	0.95 hours
Nurse aide	2.31 hours	2.03 hours
Weekend nurse staffing	3.05 hours	2.99 hours

0.18 hours above this site’s computed Texas average.

Total nursing staff turnover: 60.9% (Texas average computed on this site: 50.8%, n=1,096)
RN turnover: 66.7%
Average residents per day: 101.9
Certified beds (CMS): 121

Penalties in the CMS Provider Information file: 3 finestotaling $41,215; 3 total penalties. These are the figures CMS published in this release. Confirm current figures on Medicare.gov.

Fines and payment denials

Individual fines and payment denials below come from the CMS Penalties file (official release October 28, 2026; processing date October 1, 2026). Dates and amounts are copied as published. They can lag later actions or successful appeals. Confirm current figures on Medicare.gov.

CMS fines and payment denials
Date	Type	Fine amount	Payment denial
November 15, 2024	Fine · Fine ID 113380	$11,466	—
March 7, 2024	Fine · Fine ID 112663	$15,851	—
January 23, 2024	Fine · Fine ID 112344	$13,898	—

MDS quality measures

These figures are the four-quarter averages published in the CMS MDS Quality Measures file (official release October 28, 2026; measure period 2025Q3-2026Q2; processing date October 1, 2026). They are not a grade this site assigned. A “used in Five-Star” flag is the published CMS field that says whether that measure feeds the quality-measure star rating. Quarterly scores are collapsed under each measure. Official definitions are on the CMS Five-Star page.

CMS MDS quality measures, four-quarter averages
Measure	Stay	Four-quarter average	Used in Five-Star QM rating
Percentage of long-stay residents whose need for help with daily activities has increased Quarterly scores Q1 26.8% · Q2 15.6% · Q3 25.7% · Q4 16.2% · Period 2025Q3-2026Q2 · Measure code 401	Long Stay	21.2%	Yes, as published by CMS
Percentage of long-stay residents with a catheter inserted and left in their bladder Quarterly scores Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 406	Long Stay	0.0%	Yes, as published by CMS
Percentage of long-stay residents with a urinary tract infection Quarterly scores Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 407	Long Stay	0.0%	Yes, as published by CMS
Percentage of long-stay residents experiencing one or more falls with major injury Quarterly scores Q1 2.6% · Q2 1.4% · Q3 1.3% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 410	Long Stay	1.3%	Yes, as published by CMS
Percentage of long-stay residents whose ability to walk independently worsened Quarterly scores Q1 40.2% · Q2 17.6% · Q3 18.2% · Q4 8.8% · Period 2025Q3-2026Q2 · Measure code 451	Long Stay	23.3%	Yes, as published by CMS
Percentage of long-stay residents with pressure ulcers Quarterly scores Q1 1.2% · Q2 1.1% · Q3 1.9% · Q4 2.0% · Period 2025Q3-2026Q2 · Measure code 479	Long Stay	1.6%	Yes, as published by CMS
Percentage of long-stay residents who received an antipsychotic medication Quarterly scores Q1 5.5% · Q2 8.2% · Q3 12.9% · Q4 12.1% · Period 2025Q3-2026Q2 · Measure code 481	Long Stay	9.8%	Yes, as published by CMS
Percentage of long-stay residents who lose too much weight Quarterly scores Q1 1.4% · Q2 1.7% · Q3 4.5% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 404	Long Stay	1.9%	No, as published by CMS
Percentage of long-stay residents who have depressive symptoms Quarterly scores Q1 0.0% · Q2 3.6% · Q3 3.3% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 408	Long Stay	1.6%	No, as published by CMS
Percentage of long-stay residents who were physically restrained Quarterly scores Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 409	Long Stay	0.0%	No, as published by CMS
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Quarterly scores Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · Period 2025Q3-2026Q2 · Measure code 415	Long Stay	100.0%	No, as published by CMS
Percentage of long-stay residents who received an antianxiety or hypnotic medication Quarterly scores Q1 13.7% · Q2 15.2% · Q3 16.9% · Q4 18.8% · Period 2025Q3-2026Q2 · Measure code 452	Long Stay	16.1%	No, as published by CMS
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Quarterly scores Q1 — (CMS footnote 28) · Q2 — (CMS footnote 28) · Q3 — (CMS footnote 28) · Q4 — (CMS footnote 28) · Period 2025Q3-2026Q2 · Measure code 454	Long Stay	100.0%	No, as published by CMS
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Quarterly scores Q1 21.2% · Q2 18.8% · Q3 16.1% · Q4 7.8% · Period 2025Q3-2026Q2 · Measure code 480	Long Stay	15.7%	No, as published by CMS
Percentage of short-stay residents who newly received an antipsychotic medication Quarterly scores Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · Period 2025Q3-2026Q2 · Measure code 434	Short Stay	0.2%	Yes, as published by CMS
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Quarterly scores Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · Period 2025Q3-2026Q2 · Measure code 430	Short Stay	100.0%	No, as published by CMS
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Quarterly scores Q1 — (CMS footnote 28) · Q2 — (CMS footnote 28) · Q3 — (CMS footnote 28) · Q4 — (CMS footnote 28) · Period 2025Q3-2026Q2 · Measure code 472	Short Stay	98.6%	No, as published by CMS

Inspection citations

36 health citations in the CMS file (20 from complaint surveys). Highest scope/severity letter in the file: J — Isolated, immediate jeopardy.

The list below is drawn from the CMS Health Deficiencies file. We show the tag, a plain-language reading of the scope and severity letter, whether the survey was a standard or complaint survey, the survey date, and whether CMS recorded a correction. We do not reprint the official deficiency narrative here. Read that text on TULIP or Medicare.gov. A facility may appeal a finding; a successful appeal can alter or remove a citation.

Scope and severity letters (A–L)

CMS assigns one letter from a grid of scope (how widely a problem was found) and severity (how serious the harm was or could be). The short labels below are our wording of that grid, not a different rating system.

Scope and severity letters used in CMS health citations
Severity	Isolated	Pattern	Widespread
Potential for minimal harm	A	B	C
No actual harm, potential for more than minimal harm	D	E	F
Actual harm	G	H	I
Immediate jeopardy	J	K	L

2026 — 8 citations

Tag 0644D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: July 25, 2026

CMS records a correction date (August 14, 2026)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0684E

E — Pattern, potential for more than minimal harm

Complaint survey

Survey date: April 15, 2026

CMS records a correction date (April 17, 2026)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0580E

E — Pattern, potential for more than minimal harm

Complaint survey

Survey date: April 15, 2026

CMS records a correction date (April 17, 2026)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0850E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: February 12, 2026

CMS records a correction date (March 16, 2026)

More detail

Administration Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0812E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: February 12, 2026

CMS records a correction date (March 16, 2026)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0761D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: February 12, 2026

CMS records a correction date (March 16, 2026)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0755D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: February 12, 2026

CMS records a correction date (March 16, 2026)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0645D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: February 12, 2026

CMS records a correction date (March 16, 2026)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

2025 — 3 citations

Tag 0842D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: December 12, 2025

CMS records a correction date (December 15, 2025)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0550D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: November 24, 2025

CMS records a correction date (December 1, 2025)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0656D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: April 14, 2025

CMS records a correction date (May 12, 2025)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

2024 — 19 citations

Tag 0880D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: November 15, 2024

CMS records a correction date (December 10, 2024)

More detail

Infection Control Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0804D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: November 15, 2024

CMS records a correction date (December 10, 2024)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0757D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: November 15, 2024

CMS records a correction date (December 10, 2024)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0689G

G — Isolated, actual harm

Complaint survey, Standard survey

Survey date: November 15, 2024

CMS records a correction date (December 10, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0684G

G — Isolated, actual harm

Complaint survey, Standard survey

Survey date: November 15, 2024

CMS records a correction date (December 10, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0656D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: November 15, 2024

CMS records a correction date (December 10, 2024)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0641D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: November 15, 2024

CMS records a correction date (December 10, 2024)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0609D

D — Isolated, potential for more than minimal harm

Complaint survey, Standard survey

Survey date: November 15, 2024

CMS records a correction date (December 10, 2024)

More detail

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0558D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: November 15, 2024

CMS records a correction date (December 10, 2024)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0755D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: June 17, 2024

CMS records a correction date (June 18, 2024)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0584D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: June 17, 2024

CMS records a correction date (June 18, 2024)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0550D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: June 17, 2024

CMS records a correction date (June 18, 2024)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0689J

J — Isolated, immediate jeopardy

Complaint survey

Survey date: March 7, 2024

CMS records a correction date (March 8, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0656D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: March 7, 2024

CMS records a correction date (March 29, 2024)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0689J

J — Isolated, immediate jeopardy

Complaint survey

Survey date: February 7, 2024

CMS records a correction date (March 4, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0684G

G — Isolated, actual harm

Complaint survey

Survey date: February 7, 2024

CMS records a correction date (March 4, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0761E

E — Pattern, potential for more than minimal harm

Complaint survey

Survey date: January 23, 2024

CMS records a correction date (February 7, 2024)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0686D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: January 23, 2024

CMS records a correction date (February 7, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0580D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: January 23, 2024

CMS records a correction date (February 7, 2024)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

2023 — 6 citations

Tag 0693D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: October 5, 2023

Past non-compliance, as recorded by CMS (September 29, 2023)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0880E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: September 13, 2023

CMS records a correction date (October 6, 2023)

More detail

Infection Control Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0760D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: September 13, 2023

CMS records a correction date (October 6, 2023)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0690D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: September 13, 2023

CMS records a correction date (October 6, 2023)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0677D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: September 13, 2023

CMS records a correction date (October 6, 2023)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0558D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: September 13, 2023

CMS records a correction date (October 6, 2023)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

License and identity (HHSC)

License effective: April 1, 2025
License expires: April 1, 2028
Initial license date: January 31, 2017
Facility licensed: Yes
Facility certified (HHSC): Yes
Service type: MEDICARE/MEDICAID
Total licensed capacity: 121 beds
Bed mix (HHSC): Licensed only 0; Medicaid only 0; Medicare only 28; Medicare/Medicaid 93; ICF/IID 0
Alzheimer capacity: 0
Administrator: Nicole Mackey
Management company: Cow Creek Healthcare, INC

Ownership

Ownership below comes from the CMS file when a row joined on this home’s Medicare number. HHSC also records an owner and entity type; those appear after the CMS data. The HHSC entity type “HOSPITAL DISTRICT/AUTHORITY” is very common in the state roster and may not describe day-to-day control. It is not used as a headline here.

CMS ownership type: For profit - Individual · Affiliated / chain name in the file: THE ENSIGN GROUP (347 facilities in the chain, as listed)

CMS ownership records
Name	Role	Type	Share	Associated
EASTLAND MEMORIAL HOSPITAL DISTRICT	5% OR GREATER DIRECT OWNERSHIP INTEREST	Organization	100%	since 04/01/2019
MUNIZ, FELICIA	MANAGING CONTROL - GOVERNING BODY	Individual	NOT APPLICABLE	since 01/31/2017
VASSA, NEAL	MANAGING CONTROL - GOVERNING BODY	Individual	NOT APPLICABLE	since 05/30/2018
BURNAM, SOON	CORPORATE OFFICER	Individual	NOT APPLICABLE	since 01/31/2017
KEETCH, CHAD	CORPORATE OFFICER	Individual	NOT APPLICABLE	since 03/01/2011
TAYLOR, STEPHEN	CORPORATE OFFICER	Individual	NOT APPLICABLE	since 07/01/2025
COW CREEK HEALTHCARE, INC.	OPERATIONAL/MANAGERIAL CONTROL	Organization	NOT APPLICABLE	since 04/01/2019
MUNIZ, FELICIA	OPERATIONAL/MANAGERIAL CONTROL	Individual	NOT APPLICABLE	since 01/31/2017
VASSA, NEAL	OPERATIONAL/MANAGERIAL CONTROL	Individual	NOT APPLICABLE	since 05/30/2018
COW CREEK HEALTHCARE, INC.	ADP OF THE SNF	Organization	NOT APPLICABLE	since 08/14/2025
ENSIGN SERVICES INC	ADP OF THE SNF	Organization	NOT APPLICABLE	since 04/01/2019
NATIONAL HEALTH INVESTORS, INC.	ADP OF THE SNF	Organization	NOT APPLICABLE	since 04/29/2016

3 more CMS ownership records

Additional CMS ownership records
Name	Role	Type	Share	Associated
TEXAS NHI INVESTORS, LLC	ADP OF THE SNF	Organization	NOT APPLICABLE	since 04/29/2016
MUNIZ, FELICIA	ADP OF THE SNF	Individual	NOT APPLICABLE	since 01/31/2017
VASSA, NEAL	ADP OF THE SNF	Individual	NOT APPLICABLE	since 05/30/2018

HHSC owner fields

Owner (HHSC): Eastland Memorial Hospital District
Type of entity (HHSC): HOSPITAL DISTRICT/AUTHORITY

Public data compiled by NursingCareLookup, not an endorsement or a recommendation, and not medical or legal advice. This site is not affiliated with HHSC, CMS, or Medicare. Figures can lag events at the facility, including surveys, corrections, and successful appeals (an appeal can alter or remove a citation). Verify current facts on TULIP and Medicare.gov, and visit in person before you decide. HHSC roster as of November 9, 2026 (America/Chicago). CMS file: official release October 28, 2026; processing date October 1, 2026.