Cycle 1
Health 2025-06-06 · Fire 2025-06-06
12 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Houston, TX
Legend Oaks Healthcare And Rehabilitation Center -
2-star overall rating with 2-star inspections with $39,045 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
8902 West Rd, Houston, TX
(713) 849-0990
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
95
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2007-04-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.34
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.79
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,357
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.49
Baseline 22.28% · Performance 21.76% · Measure score 0.49 · Achievement 0 · Improvement 0.49
Healthcare-associated infections
6.35
Baseline 9.42% · Performance 6.39% · Measure score 6.35 · Achievement 4.83 · Improvement 6.35
Total nurse turnover
2.72
Baseline 53.97% · Performance 52.56% · Measure score 2.72 · Achievement 2.72 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.02 hours · Performance 3.16 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.81% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 14.94% · Lower 95% interval 8.03% |
| Discharge to community | 44.05% |
50.57%
6.5 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 37.04% · Lower 95% interval 32.85% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.24% |
95.27%
About the same
|
Numerator 60 · Denominator 63 |
| Falls with major injury | 1.59% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 63 |
| Discharge self-care score | 21.43% |
53.69%
32.3 pts worse
|
Numerator 9 · Denominator 42 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 24 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 63 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.39% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 5.26% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 138 |
| Staff flu vaccination coverage | 1.41% |
42%
40.6 pts worse
|
Numerator 3 · Denominator 213 |
| Discharge function score | 57.14% |
56.45%
0.7 pts better
|
Numerator 24 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 90.48% |
96.28%
5.8 pts worse
|
Numerator 19 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
2.1
1.2 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 4.0 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
97.1%
About the same
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.3% · Q2 98.7% · Q3 100.0% · Q4 98.7% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.0% |
97.9%
3.9 pts worse
|
95.5%
1.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.3%
0.3 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.8% · Q3 2.5% · Q4 3.9% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
2.7%
1 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 1.7% · Q4 1.6% · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
3.3%
0.1 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.3% · Q3 0.0% · Q4 0.0% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
18.9%
5.2 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 16.0% · Q3 14.1% · Q4 12.7% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.5% |
10.8%
7.3 pts better
|
16.7%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.9% · Q3 1.9% · Q4 2.2% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.7% |
15.4%
5.3 pts worse
|
16.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 46.3% · Q3 9.9% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.1% |
16.1%
3 pts worse
|
14.9%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 31.3% · Q3 11.1% · Q4 4.8% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.9% |
15.0%
3.9 pts worse
|
19.8%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 47.1% · Q2 18.5% · Q3 8.9% · Q4 2.7% · 4Q avg 18.9% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.2%
1.9 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.0% · Q3 1.7% · Q4 2.4% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
89.7%
10.1 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.2% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.5% |
12.0%
1.5 pts worse
|
12.0%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 15.3% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.2% · Q3 1.2% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
25.9%
2.1 pts better
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 25.4% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-10 · Fire 2024-05-10
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-02 · Fire 2023-03-02
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-06-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-06-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-06-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-06
E · Potential for more than minimal harm
2024-05-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-05-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-05-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-05-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-05-10
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-05-10
E · Potential for more than minimal harm
2023-03-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-12-01
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-12-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-12-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-12-01
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-12-12
C · Minimal harm
2025-12-01
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-12-12
E · Potential for more than minimal harm
2025-06-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-06-06
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-06-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-02-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-02-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-03
F · Potential for more than minimal harm
2024-05-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-11
K · Immediate jeopardy
2024-04-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-24
K · Immediate jeopardy
2024-04-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-24
E · Potential for more than minimal harm
2023-03-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-23
E · Potential for more than minimal harm
2023-03-02
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-23
E · Potential for more than minimal harm
2023-03-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-23
Penalties and ownership
What sits behind the stars
$39,045
2024-04-23
Fine
Fine · fine $39,045
Fine
Ownership
Liberty County Hospital District No. 1
5% Or Greater Direct Ownership Interest · Organization
Ali, Nida
Operational/Managerial Control · Individual
Armstrong Healthcare, Inc.
Operational/Managerial Control · Organization
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Stratton, Charles
Corporate Officer · Individual
Vincent, James
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Paradigm at Woodwind Lakes
Houston, TX
0-star overall rating with 0-star inspections with Special Focus status with $265,534 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Fallbrook Rehabiliation and Care Center
Houston, TX
1-star overall rating with 1-star inspections with $173,479 in total fines with 24 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Park Manor Of Cyfair
Houston, TX
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out