The nursing home failed to ensure residents were free from significant medication errors. Cited June 2026 — limited pattern, immediate jeopardy to residents.
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F-Tag 760 — 42 CFR §483.45(f)(2) — S/S: K
Nursing home report
Legend Oaks Healthcare and Rehabilitation of Fort Worth
Registered name: Legend Oaks Healthcare and Rehabilitation - Fort W
Keller, TX · Medicare-certified · 132 beds
Needs attention
For-profitChain member
Data as of September 1, 2026
1 of 5 overall
Legend Oaks Healthcare and Rehabilitation of Fort Worth has a 1-star overall rating, with 1-star health inspection and staffing ratings, while quality measures are 4 stars. It also has a recent federal penalty, $77,433 in fines over the last 24 months, and reported nurse staffing of 3.13 hours per resident day versus the 4.1-hour federal benchmark.
Facility ratings
Health inspections
Staffing
3.1293 hrs/resident/day
Quality measures
Last inspection: June 30, 2026Penalties, last 24 months: $77,433recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.1293.
Staffing detail
- Registered nurses
- 0.49
- Licensed practical nurses
- 0.87
- Nurse aides
- 1.76
- Weekend nursing
- 2.72
Hours per resident per day.
Total staff turnover: 68%
Registered nurse turnover: 63%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
1.7%4.9%Worsening
Residents with a fall causing major injury
3.1%3%No change
Residents with pressure ulcers (bedsores)
4.7%2.9%Improving
Residents with a urinary tract infection
1.1%0%Improving
Residents who lost too much weight
2.3%1.1%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
18.5%8.9%Improving
Residents whose ability to walk got worse
19.3%9.2%Improving
Long-stay residents on antianxiety or sleep medication
9%10.4%Worsening
Short-stay residents newly given an antipsychotic
1.7%2.7%Worsening
Residents with a long-term catheter
1.1%0.7%No change
Residents with new or worsening incontinence
8.1%14.4%Worsening
Residents with depressive symptoms
3.4%1.1%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
97.9%95%Worsening
Short-stay residents given the seasonal flu vaccine
—75.9%—
Short-stay residents given the pneumonia vaccine
90%67.2%Worsening
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited September 2025 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: J
The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited March 2026 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
The nursing home failed to protect residents from abuse and neglect by others. Cited February 2025 — isolated incident, actual harm.
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F-Tag 600 — 42 CFR §483.12 — S/S: G
The home failed to have and follow a policy for how food brought in by family and visitors should be used and stored safely. Cited June 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 813 — 42 CFR §483.60 — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal fine of $11,850 was recorded.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal fine of $19,135 was recorded.
- PENALTY
A federal fine of $18,150 was recorded.
- INSPECTION
Health inspection found 7 health deficiencies.
See what inspectors found
- PENALTY
A federal fine of $10,361 was recorded.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal fine of $9,110 was recorded.
- PENALTY
A federal fine of $8,827 was recorded.
Penalties & enforcement
On record with Medicare: 6 fines · $77,433 in total fines.
- $11,850
Federal fine
Jun 13, 2026
- $19,135
Federal fine
Mar 5, 2026
- $18,150
Federal fine
Mar 5, 2026
- $10,361
Federal fine
Sep 11, 2025
- $9,110
Federal fine
Feb 26, 2025
- $8,827
Federal fine
Oct 8, 2024
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of THE ENSIGN GROUP · 344 homes · 3.2 stars avg
- Occupancy
- 106.7 residents on an average day (81% of 132 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 9 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.