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🔎 Legend Oaks Healthcare And Rehabilitation - Ennis

Inspection Results


Inspection Overview

Legend Oaks Healthcare And Rehabilitation - Ennis has been cited for a total of 25 deficiencies since we began saving each survey.

In Texas, the average facility has **34.42 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2025-02-27
Correction Date: 2025-02-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2025-02-27
Correction Date: 2025-02-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2024-07-01
Correction Date: 2024-07-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2024-07-01
Correction Date: 2024-07-01
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-01-11
Correction Date: 2024-01-18
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-01-11
Correction Date: 2024-01-18
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2024-01-11
Correction Date: 2024-01-18
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-08-17
Correction Date: 2023-08-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2022-12-01
Correction Date: 2023-01-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-12-01
Correction Date: 2023-01-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2022-12-01
Correction Date: 2023-01-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2022-12-01
Correction Date: 2023-01-13
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-12-01
Correction Date: 2023-01-13
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2022-01-06
Correction Date: 2022-02-11
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2021-12-05
Correction Date: 2021-12-23
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-09-09
Correction Date: 2021-10-06
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Survey Date: 2021-09-09
Correction Date: 2021-10-06
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-12-14
Correction Date: 2021-01-21
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-08-09
Correction Date: 2019-08-30
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: B

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2018-06-14
Correction Date: 2018-07-19
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

Ensure each resident receives an accurate assessment.

Survey Date: 2018-06-14
Correction Date: 2018-07-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2018-06-14
Correction Date: 2018-07-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2018-06-14
Correction Date: 2018-07-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2018-06-14
Correction Date: 2018-07-19
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2018-06-14
Correction Date: 2018-07-19
Category: Environmental Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**