D
PLEASANT MANOR HEALTHCARE REHABILITATION
48/100 score
0.40 hrs RN staffing
8 deficiencies
LEGEND OAKS HEALTHCARE AND REHABILITATION - WAXAHA
151 COUNTRY MEADOWS BOULEVARD, WAXAHACHIE, TX 75165
F
Facility Assessment
5 federal violations at this facility remain unresolved. Inspectors recorded 5 citations at the actual-harm level or worse in the last three survey cycles. This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.
Below the repealed 0.55 hr RN benchmark — review inspection history before visiting.
Quality Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
0.37 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
33
Outstanding
5
Actual harm or worse (G–L)
5
|
|
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
|
Quality: ★★☆☆☆ (2/5)
Staffing: ★☆☆☆☆ (1/5)
|
|
NursingHomeGrade Score
|
0/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
2 immediate jeopardy, 3 actual harm issues found among 33 total deficiencies. 28 corrected. — 5 still outstanding
Most recent inspection (February 12, 2026)
E
Potential harm — pattern
F0850
Status: Outstanding — No Plan
Hire a qualified full-time social worker in a facility with more than 120 beds.
Administration Deficiencies — Deficient, Provider has no plan of correction
E
Potential harm — pattern
F0812
Status: Outstanding — No Plan
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has no plan of correction
D
Potential harm — isolated
F0755
Status: Outstanding — No Plan
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has no plan of correction
D
Potential harm — isolated
F0761
Status: Outstanding — No Plan
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.
Pharmacy Service Deficiencies — Deficient, Provider has no plan of correction
D
Potential harm — isolated
F0645
Status: Outstanding — No Plan
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction
D
Potential harm — isolated
F0842
Status: Corrected
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2025
D
Potential harm — isolated
F0656
Status: Corrected
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 12, 2025
D
Potential harm — isolated
F0550
Status: Corrected
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 1, 2025
Inspection cycle 2 (November 15, 2024)
D
Potential harm — isolated
F0609
Status: Corrected
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
D
Potential harm — isolated
F0804
Status: Corrected
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
D
Potential harm — isolated
F0755
Status: Corrected
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected June 18, 2024
D
Potential harm — isolated
F0757
Status: Corrected
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
G
Actual harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
G
Actual harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
D
Potential harm — isolated
F0641
Status: Corrected
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
D
Potential harm — isolated
F0656
Status: Corrected
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
D
Potential harm — isolated
F0550
Status: Corrected
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 18, 2024
D
Potential harm — isolated
F0584
Status: Corrected
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 18, 2024
D
Potential harm — isolated
F0558
Status: Corrected
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
Inspection cycle 3 (September 13, 2023)
E
Potential harm — pattern
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2023
E
Potential harm — pattern
F0761
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 7, 2024
D
Potential harm — isolated
F0760
Status: Corrected
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2023
J
Immediate jeopardy — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 8, 2024
G
Actual harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 4, 2024
J
Immediate jeopardy — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 4, 2024
D
Potential harm — isolated
F0686
Status: Corrected
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 7, 2024
D
Potential harm — isolated
F0693
Status: Corrected
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.
Quality of Life and Care Deficiencies — Past Non-Compliance, corrected September 29, 2023
D
Potential harm — isolated
F0677
Status: Corrected
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2023
D
Potential harm — isolated
F0690
Status: Corrected
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2023
D
Potential harm — isolated
F0656
Status: Corrected
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 29, 2024
D
Potential harm — isolated
F0580
Status: Corrected
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 7, 2024
D
Potential harm — isolated
F0558
Status: Corrected
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2023
How We Stay Independent
NursingHomeGrade is strictly independent. We do not accept payments from facilities. Our grades are calculated solely from federal CMS datasets.
Learn about our data methodology →Nearby facilities in WAXAHACHIE
Compare local nursing homes using the same CMS-backed grading method.
Need help choosing a facility?
Get free guidance from senior living advisors. We may earn a referral fee from comparison services, but never from nursing facilities and never in ways that affect grades.
Get help finding alternatives ↗ Compare nearby ↗↗ Links open independent third-party sites in a new tab.
Get score alerts for this facility
We'll email you when LEGEND OAKS HEALTHCARE AND REHABILITATION - WAXAHA's staffing score changes.