Legend Oaks Healthcare and Rehabilitation - Fort W
4240 Golden Triangle Boulevard · Keller, TX · 76244 · 8178066400
132 certified beds For profit - Limited Liability company Chain: The Ensign Group Hospital-based
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $65,583 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$65,583 in federal fines in the last 24 months
5 fines — CMS fines are reserved for verified, serious non-compliance.
69% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.18 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.54 | 0.55–0.75 |
| Weekend hours / resident-day | 2.74 | ≈ weekday level |
| Nursing turnover / year | 69% | median 45% |
| Fines (3-yr window) | 5 · $65,583 |
Inspection citations (23 in the current record)
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Actual harm · H April 17, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 27, 2026 · Quality of Life and Care
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Actual harm · G March 26, 2026 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected April 22, 2026 · Quality of Life and Care
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Potential for harm · D March 5, 2026
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 3, 2026 · Resident Assessment and Care Planning
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Potential for harm · D March 5, 2026
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected April 3, 2026 · Quality of Life and Care
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Potential for harm · D March 5, 2026
Provide safe and appropriate respiratory care for a resident when needed.
Corrected April 3, 2026 · Quality of Life and Care
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Potential for harm · D March 5, 2026
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 3, 2026 · Pharmacy Service
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Potential for harm · E March 5, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 3, 2026 · Nutrition and Dietary
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Potential for harm · E March 5, 2026
Dispose of garbage and refuse properly.
Corrected April 3, 2026 · Nutrition and Dietary
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Potential for harm · E March 5, 2026
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected April 3, 2026 · Resident Assessment and Care Planning
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Immediate jeopardy · J September 11, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 29, 2025 · Quality of Life and Care
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Actual harm · G February 26, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 30, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 19, 2024
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.
Corrected December 20, 2024 · Quality of Life and Care
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Potential for harm · D December 19, 2024
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected December 20, 2024 · Quality of Life and Care
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Potential for harm · D December 19, 2024
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected December 20, 2024 · Quality of Life and Care
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Immediate jeopardy · J October 8, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 23, 2024 · Quality of Life and Care
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Potential for harm · D October 8, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 10, 2024 · Quality of Life and Care
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Potential for harm · D June 6, 2024 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected June 30, 2024 · Resident Rights
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Potential for harm · D June 6, 2024 · found via complaint
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected June 30, 2024 · Resident Assessment and Care Planning
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Potential for harm · D November 16, 2023
Reasonably accommodate the needs and preferences of each resident.
Corrected November 17, 2023 · Resident Rights
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Potential for harm · D November 16, 2023
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected November 17, 2023 · Resident Assessment and Care Planning
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Potential for harm · E November 16, 2023
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected November 17, 2023 · Nursing and Physician Services
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Potential for harm · D November 16, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected November 17, 2023 · Pharmacy Service
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Potential for harm · E November 16, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 17, 2023 · Nutrition and Dietary
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 5, 2026 | Fine | $18,150 |
| March 5, 2026 | Fine | $19,135 |
| September 11, 2025 | Fine | $10,361 |
| February 26, 2025 | Fine | $9,110 |
| October 8, 2024 | Fine | $8,827 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 676426 · certified since June 1, 2017. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.