Legend Oaks Healthcare And Rehabilitation - Fort W faces challenges in its CMS ratings, earning a D grade with a score of 52/100. The facility ranks in the 58th percentile among Texas nursing homes, suggesting significant room for improvement.
With 3.21 total nurse hours per resident per day, Legend Oaks Healthcare And Rehabilitation - Fort W 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 18 deficiencies at Legend Oaks Healthcare And Rehabilitation - Fort W, including 3 classified as serious — among the most concerning citation levels. The most notable finding involved: ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents..
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 3.21 | 3.8 | Below Average |
| Registered Nurses (RN) | 0.44 | 0.7 | Below Average |
| Licensed Practical Nurses (LPN) | 1.02 | 0.7 | Above Average |
| Certified Nursing Assistants (CNA) | 1.75 | 2.4 | Below Average |
| Weekend Total Nursing | 2.70 | 3.8 | Below Average |
| Weekend RN Hours | 0.27 | 0.7 | Below Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0689 Severity JEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Sep 10, 2025 · Quality of Life and Care Deficiencies
- Tag 0600 Severity GProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Feb 25, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
- Tag 0693 Severity DEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a fDec 18, 2024 · Quality of Life and Care Deficiencies
- Tag 0694 Severity DProvide for the safe, appropriate administration of IV fluids for a resident when needed.Dec 18, 2024 · Quality of Life and Care Deficiencies
- Tag 0698 Severity DProvide safe, appropriate dialysis care/services for a resident who requires such services.Dec 18, 2024 · Quality of Life and Care 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 | 3.7% | 4.5% | Better |
| Falls with major injury | 2.6% | 3.0% | Better |
| On antipsychotic medication | 3.6% | 14.5% | Better |
| Urinary tract infections | 0.3% | 2.5% | Better |
| ADL decline (daily activities) | 18.8% | 14.0% | Worse |
| Excessive weight loss | 4.5% | 7.5% | Better |
| New/worsened incontinence | 15.5% | 45.0% | Better |
⚠️ Penalties & Fines
4 penalties recorded by CMS
Total fines: $50,633
How This Grade Was Calculated
This facility's grade of D is based on a score of 52 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 4★ → 32 pts (max 40)
- Health Inspection Rating: 4★ → 20 pts (max 25)
- Staffing Rating: 2★ → 8 pts (max 20)
- Quality Measures Rating: 4★ → 12 pts (max 15)
- Penalty deductions: -15 pts
- Fine deductions: -5 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
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