Provider Name: LEGEND OAKS HEALTHCARE AND REHABILITATION - WAXAHA
Address: 151 COUNTRY MEADOWS BOULEVARD, WAXAHACHIE, TX 75165
Phone: (972) 937-1650
County: Ellis (470)
Ownership Type: For profit - Corporation
Certified Beds: 121
Average Residents Per Day: 100. ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: EASTLAND MEMORIAL HOSPITAL DISTRICT
First Approved Date: January 31, 2017
Affiliated Entity: THE ENSIGN GROUP (507)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 1 ()
Health Inspection Rating: 1 ()
QM Rating: 4 ()
Long Stay QM Rating: 4 ()
Short Stay QM Rating: 3 ()
Staffing Rating: 1 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.00640, LPN Staff Hours Per Day: 0.9288, RN Staff Hours Per Day: 0.3330, Licensed Staff Hours Per Day: 1.2618
Total Nurse Staff Hours Per Day, per resident: 3.26828
Weekend Nurse Staff Hours: 2.86429, Weekend RN Staff Hours: 0.2700
PT Staff Hours Per Day, per resident: 0.1714
Nurse Staff Turnover: 60.9, Nurse Turnover Note:
RN Turnover: 44.4, RN Turnover Note:
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.0827, Case Mix LPN Hours Per Day: 0.7735, Case Mix RN Hours Per Day: 0.3979
Adjusted Nurse Aide Hours Per Day, per resident: 1.96252, Adjusted LPN Hours Per Day: 0.8861, Adjusted RN Hours Per Day: 0.3153
Total Adjusted Nurse Hours Per Day, per resident: 3.16562
Adjusted Weekend Nurse Hours Per Day, per resident: 2.77431
Health Survey Dates and Scores: Cycle 1: 2022-07-24 (Score: 257), Cycle 2: 2021-06-10 (Score: 36), Cycle 3: 2019-02-22 (Score: 20)
Total Weighted Health Score: 143.83
Reported Incidents: 1, Substantiated Complaints: 3
Infection Control Citations: 1
Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 310869.00, Payment Denials Number: 1, Total Penalties Number: 3
Location and GPS: 151 COUNTRY MEADOWS BOULEVARD,WAXAHACHIE,TX,75165 (32.4486, -96.778)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: 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 - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Past Non-Compliance on 2023-10-05
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: K - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-15
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: K - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-15
Type: Health, Deficiency: 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 - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-15
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-15
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-15
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-01
Type: Health, Deficiency: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-07-25
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-07-25
Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-11-12
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0293, Version: New
Description: Have properly located and lighted "Exit" signs.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-21
Type: Fire Safety, Tag: 0351, Version: New
Description: Install an approved automatic sprinkler system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-21
Type: Fire Safety, Tag: 0511, Version: New
Description: Have properly installed electrical wiring and gas equipment.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-21
Type: Fire Safety, Tag: 0923, Version: New
Description: Have proper medical gas storage and administration areas.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-21