LEGEND OAKS HEALTHCARE AND REHABILITATION - WAXAHA
State inspectors recorded 2 immediate-jeopardy citation(s) here in the last three years — CMS's most serious level.
Serious inspection findings
2024-11-15 — ACTUAL HARM (tag F0684, severity G)
Quality of Life and Care Deficiencies · correction not recorded in CMS data
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2024-11-15 — ACTUAL HARM (tag F0689, severity G)
Quality of Life and Care Deficiencies · correction not recorded in CMS data
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2024-03-07 — IMMEDIATE JEOPARDY (tag F0689, severity J)
Quality of Life and Care Deficiencies · correction not recorded in CMS data
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2024-02-07 — IMMEDIATE JEOPARDY (tag F0689, severity J)
Quality of Life and Care Deficiencies · correction not recorded in CMS data
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2024-02-07 — ACTUAL HARM (tag F0684, severity G)
Quality of Life and Care Deficiencies · correction not recorded in CMS data
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Staffing, from payroll records
Nursing hours / resident / day
2.14
state median 2.67
Weekend staffing gap
−1%
fewer nursing hours on weekends · state median −7%
RN hours / resident / day
0.21
registered nurses only
Contract (agency) staff
0%
share of all nursing hours
Nursing staff turnover
58%
per year, per CMS
Keep an eye on this facility
Penalties and enforcement
3 enforcement action(s), totaling $41,215 in fines.
| Date | Type | Amount |
|---|---|---|
| 2024-11-15 | Fine | $11,466 |
| 2024-03-07 | Fine | $15,851 |
| 2024-01-23 | Fine | $13,898 |
Ownership
Ownership type: For profit - Individual. Part of the THE ENSIGN GROUP chain.
Other facilities under the same ownership, with their CMS overall ratings:
- THE HEALTHCARE CENTER OF EASTVIEW (BIRMINGHAM, AL) —
- Polaris Extended Care (ANCHORAGE, AK) —
- THE HEALTH CENTER AT RESEARCH PARK (HUNTSVILLE, AL) —
- POLARIS TRANSITIONAL CARE (ANCHORAGE, AK) —
- Desert Terrace Healthcare Center (PHOENIX, AZ) —
- PUEBLO SPRINGS REHABILITATION CENTER (TUCSON, AZ) —
- CASAS ADOBES POST ACUTE REHAB CENTER (TUCSON, AZ) —
- MISSION PALMS POST ACUTE (MESA, AZ) —
Full citation history
| Survey date | Tag | Category | Severity | Corrected |
|---|---|---|---|---|
| 2026-04-15 | F0580 | Resident Rights Deficiencies | E | not recorded |
| 2026-04-15 | F0684 | Quality of Life and Care Deficiencies | E | not recorded |
| 2026-02-12 | F0645 | Resident Assessment and Care Planning Deficiencies | D | not recorded |
| 2026-02-12 | F0755 | Pharmacy Service Deficiencies | D | not recorded |
| 2026-02-12 | F0761 | Pharmacy Service Deficiencies | D | not recorded |
| 2026-02-12 | F0812 | Nutrition and Dietary Deficiencies | E | not recorded |
| 2026-02-12 | F0850 | Administration Deficiencies | E | not recorded |
| 2025-12-12 | F0842 | Resident Assessment and Care Planning Deficiencies | D | not recorded |
| 2025-11-24 | F0550 | Resident Rights Deficiencies | D | not recorded |
| 2025-04-14 | F0656 | Resident Assessment and Care Planning Deficiencies | D | not recorded |
| 2024-11-15 | F0558 | Resident Rights Deficiencies | D | not recorded |
| 2024-11-15 | F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | D | not recorded |
| 2024-11-15 | F0641 | Resident Assessment and Care Planning Deficiencies | D | not recorded |
| 2024-11-15 | F0656 | Resident Assessment and Care Planning Deficiencies | D | not recorded |
| 2024-11-15 | F0684 | Quality of Life and Care Deficiencies | G | not recorded |
| 2024-11-15 | F0689 | Quality of Life and Care Deficiencies | G | not recorded |
| 2024-11-15 | F0757 | Pharmacy Service Deficiencies | D | not recorded |
| 2024-11-15 | F0804 | Nutrition and Dietary Deficiencies | D | not recorded |
| 2024-11-15 | F0880 | Infection Control Deficiencies | D | not recorded |
| 2024-06-17 | F0550 | Resident Rights Deficiencies | D | not recorded |
| 2024-06-17 | F0584 | Resident Rights Deficiencies | D | not recorded |
| 2024-06-17 | F0755 | Pharmacy Service Deficiencies | D | not recorded |
| 2024-03-07 | F0656 | Resident Assessment and Care Planning Deficiencies | D | not recorded |
| 2024-03-07 | F0689 | Quality of Life and Care Deficiencies | J | not recorded |
| 2024-02-07 | F0684 | Quality of Life and Care Deficiencies | G | not recorded |
| 2024-02-07 | F0689 | Quality of Life and Care Deficiencies | J | not recorded |
| 2024-01-23 | F0580 | Resident Rights Deficiencies | D | not recorded |
| 2024-01-23 | F0686 | Quality of Life and Care Deficiencies | D | not recorded |
| 2024-01-23 | F0761 | Pharmacy Service Deficiencies | E | not recorded |
| 2023-10-05 | F0693 | Quality of Life and Care Deficiencies | D | not recorded |
| 2023-09-13 | F0558 | Resident Rights Deficiencies | D | not recorded |
| 2023-09-13 | F0677 | Quality of Life and Care Deficiencies | D | not recorded |
| 2023-09-13 | F0690 | Quality of Life and Care Deficiencies | D | not recorded |
| 2023-09-13 | F0760 | Pharmacy Service Deficiencies | D | not recorded |
| 2023-09-13 | F0880 | Infection Control Deficiencies | E | not recorded |