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Legend Oaks Healthcare And Rehabilitation-West Hou

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About Legend Oaks Healthcare And Rehabilitation-West Hou

General Information

Legal Business NameLegend Oaks - West Houston, LLC
Ownership TypeFor Profit - Partnership
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareAugust 12, 2009 (7 years)
Capacity124
Residents116
Percent Occupied94%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsBoth
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Legend Oaks Healthcare And Rehabilitation-West Hou

Legend Oaks Healthcare And Rehabilitation-West Hou
was reviewed by Medicare to have a rating of 4 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

August 14, 2015 - 16 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
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 HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential 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.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmHealth InspectionEnsure that residents are fully informed and understand their health status, care and treatments.
ESomePotential for HarmHealth InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
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.

August 13, 2015 - 16 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmFire Safety InspectionProperly installed hallway dispensers for alcohol-based hand rub.
ESomePotential for HarmFire Safety InspectionProperly protected cooking facilities.
ESomePotential for HarmFire Safety InspectionA fire alarm system that can be heard throughout the facility.
ESomePotential for HarmFire Safety InspectionProper backup exit lighting.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.

July 31, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
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 InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.

July 29, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionExits that are free from obstructions and can be used at all times.
FManyPotential for HarmFire Safety InspectionAn approved installation, maintenance and testing program for fire alarm systems.
ESomePotential for HarmFire Safety InspectionProper medical gas storage and administration areas.
CManyPotential for Minimal HarmFire Safety InspectionWeekly inspections and monthly testing of generators.
DFewPotential for HarmFire Safety InspectionPortable fire extinguishers.
DFewPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.

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-West Hou 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.

3hr 25min
2hr 30min
ReportedExpected
CNA
2hr
45min
ReportedExpected
LPN
55min
1hr 25min
ReportedExpected
RN
6hr 20min
4hr 35min
ReportedExpected
Total Nursing

This facility also provides approximately 35min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

96.7%
96.8%
96.8%
90.7%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Seasonal Influenza Vaccine
98.9%
98.9%
97.8%
87.9%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
66.7%
71.0%
-
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
33.7%
31.0%
23.6%
22.3%
Q1 2015Q2 2015Q3 2015TX
Received an Antipsychotic Medication
21.1%
25.0%
27.0%
19.6%
Q1 2015Q2 2015Q3 2015TX
Need for Help with ADLs has Increased
10.4%
15.1%
15.4%
8.8%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
6.8%
5.7%
8.5%
6.3%
Q1 2015Q2 2015Q3 2015TX
Lose Too Much Weight
3.8%
5.6%
4.3%
6.6%
Q1 2015Q2 2015Q3 2015TX
High Risk Residents With Pressure Ulcers
1.2%
1.2%
2.3%
6.1%
Q1 2015Q2 2015Q3 2015TX
Have Depressive Symptoms
6.8%
4.5%
8.5%
5.1%
Q1 2015Q2 2015Q3 2015TX
With a Urinary Tract Infection
2.2%
3.4%
5.5%
3.5%
Q1 2015Q2 2015Q3 2015TX
Experiencing One or More Falls with Major Injury
0.9%
2.0%
3.0%
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

64.7%
66.7%
70.2%
71.4%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
38.6%
38.6%
38.6%
71.1%
Q1 2015Q2 2015Q3 2015TX
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
29.2%
31.8%
32.7%
16.5%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
0.0%
1.4%
1.4%
3.2%
Q1 2015Q2 2015Q3 2015TX
Newly Received an Antipsychotic Medication
1.5%
1.8%
0.9%
1.0%
Q1 2015Q2 2015Q3 2015TX
With Pressure Ulcers That Are New or Worsened