Federal inspection record · CMS data as of October 1, 2026
Legend Oaks Healthcare and Rehabilitation Center -
8902 West Rd, Houston, TX · (713) 849-0990
- Certified beds
- 125
- Residents per day
- 105
- Ownership
- Government
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- April 25, 2007
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Texas homes
Legend Oaks Healthcare and Rehabilitation Center - carries 115.25 inspection points. That is fewer than 28% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
24 health citations on record since 2024. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (3)
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G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
K
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Pharmacy Service5E
- D
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.
- D
Ensure that residents are free from significant medication errors.
- D
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.
- E
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Nutrition and Dietary4F
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Dispose of garbage and refuse properly.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Assessment and Care Planning4E
- D
Ensure each resident receives an accurate assessment.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Infection Control2D
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Quality of Life and Care2D
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Nursing and Physician Services2D
- D
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.
- C
Post nurse staffing information every day.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Environmental1D
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspection history
2026-08-13
13 health deficiencies · 4 fire-safety deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2025-06-06
8 health deficiencies · 4 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2024-05-10
3 health deficiencies · 5 fire-safety deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4
Nursing time per resident, per day
Each resident here gets about 3 h 18 min of nursing staff time a day, 26 min of it from a registered nurse.
This home
3 h 18 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 62% of nursing staff and 46% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$53,425 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2026-08-13 | Fine | $14,380 |
| 2024-04-23 | Fine | $39,045 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.7 pts worse | 2.7 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.4 pts worse | 3.4 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.3 pts worse | 96.1% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine19.3 pts worse | 77.7% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.4 pts worse | 3.6% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms0.7 pts better | 1.6% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight1 pts better | 1.9% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication5.3 pts better | 12.5% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication6.1 pts better | 3.7% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened3.4 pts better | 9.5% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increasedAbout the same | 15.8% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.8 pts better | 0.0% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence0.3 pts better | 12.2% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.1 pts worse | 3.8% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine0.6 pts better | 89.3% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit3.9 pts better | 8.3% | 12.2% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.4 pts better | 0.0% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine6.4 pts worse | 79.0% | 85.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission12.8 pts better | 12.7% | 25.5% | 23.4% |
·
Who owns and runs it
15 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Liberty County Hospital District No 1 | 5% Or Greater Direct Ownership Interest · Organization | 100% | 35 facilities |
| Ali, Nida | Managing Control - Governing Body · Individual | 0% | 5 facilities |
| Ali, Nida | Operational/Managerial Control · Individual | 0% | 5 facilities |
| Ali, Nida | Adp Of The SNF · Individual | 0% | 5 facilities |
| Armstrong Healthcare, Inc. | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Armstrong Healthcare, Inc. | Adp Of The SNF · Organization | 0% | 1 facilities |
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| National Health Investors, Inc. | Adp Of The SNF · Organization | 0% | 31 facilities |
| Stratton, Charles | Corporate Officer · Individual | 0% | 35 facilities |
| Texas Nhi Investors, LLC | Adp Of The SNF · Organization | 0% | 19 facilities |
| Vincent, James | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Vincent, James | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Vincent, James | Adp Of The SNF · Individual | 0% | 1 facilities |
·
Fire safety
13 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke9E
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Install corridor and hallway doors that block smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Install an approved automatic sprinkler system.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Provide properly protected cooking facilities.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Services1E
- E
Have properly installed electrical wiring and gas equipment.
Gas, Vacuum, and Electrical Systems1E
- E
Ensure proper usage of power strips and extension cords.
Egress1E
- E
Have properly located and lighted "Exit" signs.
Miscellaneous1E
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
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Other homes nearby
-
Paradigm at Woodwind Lakes
Houston, TX · Paradigm Healthcare · Special Focus
Not rated- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 3 h 26 min
- Fines
- $89,541
-
Fallbrook Rehabilitation and Care Center
Houston, TX · Special Focus
★★★★★- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 3 h 21 min
- Fines
- $70,494
-
Park Manor Of Cyfair
Houston, TX · Hmg Healthcare
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 1 min
- Fines
- $0