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Legend Oaks Healthcare And Rehabilitation Center -

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About Legend Oaks Healthcare And Rehabilitation Center -

General Information

Legal Business NamePend Oreille River Associates, LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareApril 25, 2007 (10 years)
Capacity125
Residents92
Percent Occupied74%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Legend Oaks Healthcare And Rehabilitation Center -

Legend Oaks Healthcare And Rehabilitation Center -
was reviewed by Medicare to have a rating of 1 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Texas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

July 30, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
HSomeActual HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
HSomeActual HarmHealth InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
FManyPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
FManyPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
FManyPotential for HarmComplaint+InspectionMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
FManyPotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FManyPotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
ESomePotential for HarmComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionEnsure residents maintain acceptable nutritional status.
DFewPotential for HarmHealth InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
DFewPotential for HarmHealth InspectionEnsure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.
DFewPotential for HarmComplaint+Inspection1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
DFewPotential for HarmHealth InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
DFewPotential for HarmHealth InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.

July 29, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
DFewPotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.

July 7, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
HSomeActual HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
GFewActual HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
DFewPotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

May 20, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 76 days
DFewPotential for HarmComplaintDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
DFewPotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

February 12, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
DFewPotential for HarmComplaintHave a program that investigates, controls and keeps infection from spreading.

January 17, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 8 days
LManyImmediate JeopardyComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
LManyImmediate JeopardyComplaintMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
LManyImmediate JeopardyComplaintDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
LManyImmediate JeopardyComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
LManyImmediate JeopardyComplaintProtect each resident from mistreatment, neglect and misappropriation of personal property.
ESomePotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
DFewPotential for HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmComplaintProvide care by qualified persons according to each resident's written plan of care.

November 21, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintProvide timely notification to the resident before transfer or discharge.

October 30, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.

June 18, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaint+InspectionHave a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents.
GFewActual HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
ESomePotential for HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
ESomePotential for HarmHealth InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
ESomePotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
ESomePotential for HarmFire Safety InspectionPosted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
ESomePotential for HarmFire Safety InspectionPortable fire extinguishers.
ESomePotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
ESomePotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
CManyPotential for Minimal HarmHealth InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CManyPotential for Minimal HarmFire Safety InspectionWeekly inspections and monthly testing of generators.
DFewPotential for HarmHealth InspectionReasonably accommodate the needs and preferences of each resident.
DFewPotential for HarmHealth InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
DFewPotential for HarmHealth InspectionQuickly tell the resident's doctor the results of laboratory tests.
DFewPotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmHealth InspectionKeep complete, dated laboratory records in the resident's file.

March 6, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
CManyPotential for Minimal HarmComplaintEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Legend Oaks Healthcare And Rehabilitation Center - require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 20min
2hr 25min
ReportedExpected
CNA
1hr 15min
40min
ReportedExpected
LPN
50min
1hr 15min
ReportedExpected
RN
4hr 25min
4hr 25min
ReportedExpected
Total Nursing

This facility also provides approximately 25min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

86.4%
80.6%
80.6%
90.7%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Seasonal Influenza Vaccine
90.2%
80.6%
71.2%
87.9%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
-
-
-
46.9%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
17.6%
15.2%
15.9%
22.3%
Q1 2015Q2 2015Q3 2015TX
Received an Antipsychotic Medication
43.8%
30.5%
38.3%
19.6%
Q1 2015Q2 2015Q3 2015TX
Need for Help with ADLs has Increased
8.7%
6.4%
4.0%
8.8%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
2.4%
2.9%
8.5%
6.3%
Q1 2015Q2 2015Q3 2015TX
Lose Too Much Weight
11.9%
8.8%
13.7%
6.6%
Q1 2015Q2 2015Q3 2015TX
High Risk Residents With Pressure Ulcers
0.0%
0.0%
0.0%
6.1%
Q1 2015Q2 2015Q3 2015TX
Have Depressive Symptoms
3.7%
5.7%
2.8%
5.1%
Q1 2015Q2 2015Q3 2015TX
With a Urinary Tract Infection
2.4%
5.6%
6.8%
3.5%
Q1 2015Q2 2015Q3 2015TX
Experiencing One or More Falls with Major Injury
4.2%
7.8%
5.3%
3.3%
Q1 2015Q2 2015Q3 2015TX
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.6%
Q1 2015Q2 2015Q3 2015TX
Were Physically Restrained

Quality Measures for Short Stay Residents

51.8%
33.6%
15.7%
71.4%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
51.9%
49.1%
49.1%
71.1%
Q1 2015Q2 2015Q3 2015TX
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
20.0%
28.3%
29.3%
16.5%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
4.0%
5.6%
4.5%
3.2%
Q1 2015Q2 2015Q3 2015TX
Newly Received an Antipsychotic Medication
2.4%
3.2%
3.1%
1.0%
Q1 2015Q2 2015Q3 2015TX
With Pressure Ulcers That Are New or Worsened