Legend Oaks Healthcare And Rehabilitation - North faces challenges in its CMS ratings, earning a D grade with a score of 41/100. The facility ranks in the 45th percentile among Texas nursing homes, suggesting significant room for improvement.
With 3.12 total nurse hours per resident per day, Legend Oaks Healthcare And Rehabilitation - North falls below the national average of 3.8 hours. Families may want to ask about staffing levels during any facility visit.
Recent CMS inspections identified 28 deficiencies at Legend Oaks Healthcare And Rehabilitation - North, including 3 classified as serious — among the most concerning citation levels. The most notable finding involved: protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody..
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 3.12 | 3.8 | Below Average |
| Registered Nurses (RN) | 0.61 | 0.7 | Below Average |
| Licensed Practical Nurses (LPN) | 0.40 | 0.7 | Below Average |
| Certified Nursing Assistants (CNA) | 2.11 | 2.4 | Below Average |
| Weekend Total Nursing | 2.68 | 3.8 | Below Average |
| Weekend RN Hours | 0.50 | 0.7 | Below Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0600 Severity JProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Sep 16, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
- Tag 0607 Severity JDevelop and implement policies and procedures to prevent abuse, neglect, and theft.Sep 16, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
- Tag 0609 Severity DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Sep 16, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
- Tag 0684 Severity DProvide appropriate treatment and care according to orders, resident’s preferences and goals.Sep 16, 2025 · Quality of Life and Care Deficiencies
- Tag 0925 Severity DMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.Sep 16, 2025 · Environmental Deficiencies
📊 Resident Outcome Measures
Based on CMS quality measure data. Lower percentages are better for most metrics.
| Measure | This Facility | Nat'l Avg | |
|---|---|---|---|
| Residents with pressure ulcers | 1.9% | 4.5% | Better |
| Falls with major injury | 2.3% | 3.0% | Better |
| On antipsychotic medication | 5.1% | 14.5% | Better |
| Urinary tract infections | 0.5% | 2.5% | Better |
| ADL decline (daily activities) | 37.3% | 14.0% | Worse |
| Excessive weight loss | 2.1% | 7.5% | Better |
| New/worsened incontinence | 25.6% | 45.0% | Better |
⚠️ Penalties & Fines
1 penalty recorded by CMS
Total fines: $41,890
How This Grade Was Calculated
This facility's grade of D is based on a score of 41 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 2★ → 16 pts (max 40)
- Health Inspection Rating: 2★ → 10 pts (max 25)
- Staffing Rating: 3★ → 12 pts (max 20)
- Quality Measures Rating: 4★ → 12 pts (max 15)
- Penalty deductions: -5 pts
- Fine deductions: -4 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
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