Nursing home in Houston, Texas
Legend Oaks Healthcare and Rehabilitation Center -
Medicare and Medicaid
8902 WEST RD, Houston, TX 77064
(713) 849-0990
CMS star ratings
CMS gives this nursing home an overall star rating of 2 out of 5. Each rating is compared with the mean of rated nursing homes in Texas (1,165 for the overall rating) and in the U.S. (14,565). How to read an inspection report.
Overall rating
- This nursing home2
- Texas average2.7 (1,165 rated)
- U.S. average3.0 (14,565 rated)
Health inspections
- This nursing home2
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
- This nursing home1
- Texas average1.9 (1,163 rated)
- U.S. average2.9 (14,494 rated)
Quality measures
- This nursing home5
- Texas average3.7 (1,162 rated)
- U.S. average3.6 (14,495 rated)
Health inspections
Most recent standard health inspection (rating cycle 1): Jun 6, 2025. CMS counts 12 health deficiencies in rating cycle 1.
- This nursing home12
- Texas average9.4 (1,171 with data)
- U.S. average9.2 (14,652 with data)
Rating cycle 1 health deficiencies. Averages include every nursing home with a count in the CMS file; fewer is better.
Deficiencies since Sep 30, 2023
Inspectors cited 17 health deficiencies on 5 inspection dates since Sep 30, 2023. By level of harm: 2 immediate jeopardy, 14 potential for harm, 1 minimal harm potential.
- 2 Immediate jeopardy to resident health or safety
- 0 Actual harm
- 14 No actual harm, potential for more than minimal harm
- 1 No actual harm, potential for minimal harm
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Dec 1, 2025 | F0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Dec 1, 2025 | F0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Dec 1, 2025 | F0726 | 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.Nursing and Physician Services Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Dec 1, 2025 | F0760 | Ensure that residents are free from significant medication errors.Pharmacy Service Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Dec 1, 2025 | F0761 | 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.Pharmacy Service Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Dec 1, 2025 | F0732 | Post nurse staffing information every day.Nursing and Physician Services Deficiencies | C Minimal harm potential, widespread | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Jun 6, 2025 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jun 20, 2025 |
| Jun 6, 2025 | F0761 | 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.Pharmacy Service Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jun 20, 2025 |
| Jun 6, 2025 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jun 20, 2025 |
| Jun 6, 2025 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 20, 2025 |
Show the other 7 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Jun 6, 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 20, 2025 |
| Jun 6, 2025 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 20, 2025 |
| Feb 28, 2025 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Mar 3, 2025 |
| Feb 28, 2025 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Mar 3, 2025 |
| May 10, 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | F Potential for harm, widespread | Standard | Deficient, Provider has date of correction May 11, 2024 |
| Apr 23, 2024 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | K Immediate jeopardy, pattern | Complaint | Deficient, Provider has date of correction Apr 24, 2024 |
| Apr 23, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | K Immediate jeopardy, pattern | Complaint | Deficient, Provider has date of correction Apr 24, 2024 |
Staffing
Total nurse staffing
Reported hours per resident per day.
- This nursing home3.32 hours
- Texas average3.39 hours (1,148 with data)
- U.S. average3.86 hours (14,351 with data)
Registered nurse staffing
Reported hours per resident per day.
- This nursing home0.29 hours
- Texas average0.43 hours (1,148 with data)
- U.S. average0.69 hours (14,351 with data)
Nursing staff turnover
Share of nursing staff who left during the year, as reported to CMS.
- This nursing home70.9%
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 1 penalty for this nursing home: 1 fine totaling $39,045, and 0 payment denials. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 125 |
|---|---|
| Average residents per day | 98.7 |
| Ownership | For profit - Limited Liability company |
| Provider type | Medicare and Medicaid |
| Inside a hospital | No |
| Continuing care retirement community | No |
| Resident and family council | None |
| Automatic sprinklers in all required areas | Yes |
| Chain | The Ensign Group (344 facilities) |
| Legal business name | LIBERTY COUNTY HOSPITAL DISTRICT NO 1 |
| First approved for Medicare and Medicaid | Apr 25, 2007 |
| County | Harris |
| CMS certification number | 676137 |
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| Houston Methodist Hospital | Acute Care Hospitals | Yes | |
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