Deficiency Index

The Legacy Midtown Park

Dallas, Texas · CCN 676489

8 surveys since 2022, and no finding has been recorded at harm level.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
11
Surveys
8
Harm or worse
0
Immediate jeopardy
0
The record, 2022–2026
’22’25’26
No harm recordedHarm or worseNot surveyed
Harm or worseNone

No finding on record has been cited at harm level or above.

Beyond CMS’s monthly file2/8

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
54
Ownership
Non profit - Corporation
Chain
Independent
County
Dallas
Medicare-certified since
2020

CMS ratings

Overall
5
Health inspection
5
Staffing
5
Quality measures
4

CMS’s own Five-Star ratings.

Compared with similar facilities

Not shown for this facility: too few citations in window (n=11, floor 20).

Last survey on record

Jun 16, 2026

146 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day5.714.47
Registered-nurse hours per resident day0.72—
Annual nurse turnover33.3%37.8%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

Fines
$27,523 across 4 penalties

Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD571.4%E228.6%F—
No harm, potential for minimalA—B—C—
CMS’s current file: 7 of the 11 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F6952×

    Provide safe and appropriate respiratory care for a resident when needed.

  • F7612×

    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.

  • F8122×

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

  • F6091×

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

In the surveyor’s words

From the most serious findings on record at The Legacy Midtown Park, in the surveyor’s own words.

  • No harm, potential for more than minimal, patternF812Aug 29, 2024

    Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure on [DATE] food items in the refrigerator, freezer and dry storage room , that were not in the original packaging, were labeled. 2. The facility failed to discard items stored in refrigerator, freezers or dry storage on [DATE]. The facility had expired food items from approximately 6 months- 3 days old past the expiration date/best used by date. 3. The facility failed to remove molded fruit from the refrigerator. These failures could place residents at risk for food-borne illness and cross contamination. […]

  • No harm, potential for more than minimal, patternF812Jul 20, 2023

    Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items were kept away from potential airborne contaminants (dust and fuzz) on the mixer, knife rack, piping leading to the ice machine, and utility shelving. 2. The facility failed to ensure food items were properly covered and labeled with the contents or date the items were placed in the refrigerator in accordance with professional standards. 3. The facility failed to ensure raw beef was stored away from prepared food in the walk-in refrigerator. […]

  • No harm, potential for more than minimal, patternF883Jun 9, 2022

    Based on record review, interview, and facility policy review, the facility failed to ensure a pneumococcal vaccine was offered to three (Resident #9, Resident #14, and Resident #24) of five residents sampled for immunizations. This had the potential to result in decreased protection from pneumococcal infection. Findings included: A review of the facility's Pneumococcal Vaccine policy and procedure, revised 08/2016, indicated the following: - All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. […]

  • No harm, potential for more than minimal, isolatedF761Jun 16, 2026

    Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 resident (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's Albuterol (a fast-acting prescription inhaler used as a rescue medication that quickly opens the airways in the lungs to make breathing easier when someone is wheezing, short of breath, or having an asthma attack) was secured in the medication cart. […]

  • No harm, potential for more than minimal, isolatedF695Nov 21, 2025

    Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents (Resident #6) reviewed for respiratory care. The facility failed on 09/23/2025 to ensure Resident #6's oxygen was administered at the correct setting of 4 liters per minute per physician's orders when Resident's oxygen was set at 1 LPM.This failure could place residents at risk of developing respiratory complications. […]

Read all 11 findings in full →

Every survey on record

FindingsAt actual harm or above

  • Jun 16, 2026Complaint1 finding
  • Nov 21, 2025Complaint1 finding
  • Nov 19, 2025Complaint1 finding
  • Sep 25, 2025Standard1 finding
  • Aug 29, 2024Standard1 finding
  • Jul 20, 2023Standard2 findings
  • Jun 20, 2022Infection control1 finding
  • Jun 9, 2022Standard3 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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