Austin, TX

Legend Oaks Healthcare And Rehabilitation - North

2-star overall rating with 2-star inspections with abuse icon flag with $41,890 in total fines with 9 recent health deficiencies

11020 Dessau Rd, Austin, TX

(512) 873-2244

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

124

Certified beds

Average residents

115

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

2009-10-20

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

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.61

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.40

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.11

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.12

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.01

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.68

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.50

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.12

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.59

CMS adjusted RN staffing hours

Adjusted total hours

3.01

CMS adjusted total nurse staffing hours

Case-mix index

1.42

Higher values indicate more complex resident acuity

RN turnover

23%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

28%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,495

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

32.66

Composite VBP score used to determine payment impact.

Payment multiplier

0.9872

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.29

Baseline 21.41% · Performance 19.44% · Measure score 4.29 · Achievement 4.29 · Improvement 3.99

Healthcare-associated infections

3.76

Baseline 7.00% · Performance 6.71% · Measure score 3.76 · Achievement 3.76 · Improvement 0.92

Total nurse turnover

4.74

Baseline 46.15% · Performance 44.30% · Measure score 4.74 · Achievement 4.74 · Improvement 0.37

Adjusted total nurse staffing

0.28

Baseline 2.91 hours · Performance 3.14 hours · Measure score 0.28 · Achievement 0 · Improvement 0.28

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.94%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 129 · Observed rate 11.63% · Lower 95% interval 8.34%
Discharge to community	47.6%	50.57% 3 pts worse	No Different than the National Rate · Eligible stays 98 · Observed rate 39.8% · Lower 95% interval 39.61%
Medicare spending per beneficiary	1.05	1.02 About the same
Drug regimen review with follow-up	98.73%	95.27% 3.5 pts better	Numerator 78 · Denominator 79
Falls with major injury	1.27%	0.77% 0.5 pts worse	Numerator 1 · Denominator 79
Discharge self-care score	36.96%	53.69% 16.7 pts worse	Numerator 17 · Denominator 46
Discharge mobility score	30.43%	50.94% 20.5 pts worse	Numerator 14 · Denominator 46
Pressure ulcers or injuries, new or worsened	1.27%	2.29% 1 pts better	Numerator 1 · Denominator 79 · Adjusted rate 1.11%
Healthcare-associated infections requiring hospitalization	6.71%	7.12% 0.4 pts better	No Different than the National Rate · Eligible stays 76 · Observed rate 6.58% · Lower 95% interval 4.04%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 145
Staff flu vaccination coverage	33.14%	42% 8.9 pts worse	Numerator 56 · Denominator 169
Discharge function score	43.48%	56.45% 13 pts worse	Numerator 20 · Denominator 46
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 23 · Denominator 23
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 29 · Denominator 29
Resident COVID-19 vaccinations up to date	25%	25.2% 0.2 pts worse	Numerator 9 · Denominator 36

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.2	2.1 0.1 pts worse	1.9 0.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	2.1 0.9 pts better	1.8 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.5%	97.1% 2.4 pts better	93.4% 6.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 98.9% · Q4 100.0% · 4Q avg 99.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.3%	3.3% 1 pts better	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.0% · Q3 2.2% · Q4 4.0% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.0%	2.7% 0.3 pts worse	11.4% 8.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 3.0%
Percentage of long-stay residents who lose too much weight	2.1%	3.3% 1.2 pts better	5.4% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.5% · Q3 2.5% · Q4 0.0% · 4Q avg 2.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.0%	18.9% 3.9 pts better	19.6% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 15.9% · Q3 14.5% · Q4 14.8% · 4Q avg 15.0%
Percentage of long-stay residents who received an antipsychotic medication	5.1%	10.8% 5.7 pts better	16.7% 11.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.2% · Q3 4.5% · Q4 7.5% · 4Q avg 5.1% · 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	36.8%	15.4% 21.4 pts worse	16.3% 20.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 44.9% · Q3 39.0% · Q4 30.1% · 4Q avg 36.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	37.3%	16.1% 21.2 pts worse	14.9% 22.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 39.5% · Q3 53.9% · Q4 25.6% · 4Q avg 37.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.2%	0.5% 0.3 pts better	1.0% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.5%	0.8% 0.3 pts better	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.6%	15.0% 10.6 pts worse	19.8% 5.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 28.4% · Q3 20.0% · Q4 26.0% · 4Q avg 25.6%
Percentage of long-stay residents with pressure ulcers	1.9%	4.2% 2.3 pts better	5.1% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.3% · Q3 0.9% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	61.4%	89.7% 28.3 pts worse	81.7% 20.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 81.2% · Q2 65.9% · Q3 57.2% · Q4 46.7% · 4Q avg 61.4%
Percentage of short-stay residents who had an outpatient emergency department visit	6.1%	12.0% 5.9 pts better	12.0% 5.9 pts better	Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 6.8% · Expected 12.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.9%	1.5% 0.6 pts better	1.6% 0.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	65.7%	88.0% 22.3 pts worse	79.7% 14 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 65.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.9%	25.9% 2 pts better	23.9% About the same	Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 25.0% · Expected 25.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-20 · Fire 2025-02-20

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2023-12-13 · Fire 2023-12-13

8 health deficiencies

Top issue: Infection Control (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-10-16 · Fire 2022-10-16

11 health deficiencies

Top issue: Resident Assessment and Care Planning (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

J · Immediate jeopardy 2025-09-17

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-09-18

J · Immediate jeopardy 2025-09-17

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-09-18

D · Potential for more than minimal harm 2025-09-17

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-09-18

D · Potential for more than minimal harm 2025-09-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-09-18

D · Potential for more than minimal harm 2025-09-17

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-09-18

D · Potential for more than minimal harm 2025-04-28

F573 · Resident Rights Deficiencies

Health

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Corrected 2025-04-28

E · Potential for more than minimal harm 2025-02-20

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-02-21

E · Potential for more than minimal harm 2025-02-20

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-02-21

D · Potential for more than minimal harm 2025-02-20

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-02-21

E · Potential for more than minimal harm 2025-02-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-06

D · Potential for more than minimal harm 2025-02-05

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 2025-02-06

E · Potential for more than minimal harm 2025-01-17

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-01-20

E · Potential for more than minimal harm 2024-11-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-11

E · Potential for more than minimal harm 2024-09-13

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-09-14

D · Potential for more than minimal harm 2024-09-13

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 2024-09-14

E · Potential for more than minimal harm 2024-01-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-01-07

D · Potential for more than minimal harm 2023-12-13

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-12-14

D · Potential for more than minimal harm 2023-12-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-12-14

J · Immediate jeopardy 2022-10-16

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2022-11-28

E · Potential for more than minimal harm 2022-10-16

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2022-11-28

E · Potential for more than minimal harm 2022-10-16

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 2022-11-28

E · Potential for more than minimal harm 2022-10-16

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2022-11-28

E · Potential for more than minimal harm 2022-10-16