LEGEND OAKS HEALTHCARE AND REHABILITATION - NORTH/ - HOUSTON, TX

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Address

12921 MISTY WILLOW
HOUSTON, TX, 77070

Phone (make sure to verify first before calling): (281) 469-7881

Number of Certified Beds: 124
Total Number of Residents: 91
Percent of Occupied Beds: 73%
Sprinkler Status: Fully Sprinklered
Program Participation: Medicare and Medicaid
Type of Ownership: For profit - Corporation
Located Within a Hospital?: No
Multi Nursing Home Ownership?: Yes
Resident and Family Councils: Both
Continuing Care Retirement Community?: No
Quality Indicator Survey?: No
Special Focus Facility?: No

Overall Star Rating: 2 Stars
Health Inspections Star Rating: 2 Stars
Nurse Staffing Star Rating: 2 Stars
Quality Measures Star Rating: 4 Stars
RN Only Star Rating: 2 Stars

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

This Nursing Home:	13.5%
Texas:	20.4%

Percent of long-stay residents who self-report moderate to severe pain

This Nursing Home:	13.1%
Texas:	11.4%

Percent of long-stay high-risk residents with pressure ulcers

Here:	16.7%
State:	7.2%

Percent of long-stay residents who lose too much weight

Here:	3.2%
State:	6.7%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

Here:	3.5%
Texas:	3.9%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	14.3%
State:	8.3%

Percent of long-stay residents who have depressive symptoms

Here:	6.7%
State:	9.3%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	95.2%
State:	91.6%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	98.5%
State:	91.1%

Percent of short-stay residents who self-report moderate to severe pain

Here:	11.2%
Texas:	20.2%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	96.5%
Texas:	76.2%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	97.0%
State:	74.3%

Percent of short-stay residents who newly received an antipsychotic medication

Here:	1.8%
Texas:	3.6%

Percent of long-stay residents who received an antipsychotic medication

Here:	23.9%
Texas:	28.5%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.670
State:	0.469

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

Here:	0.930
Texas:	0.894

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.600
Texas:	1.350

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.070
Texas:	0.067

Number Therapy Hours Per Resident Per Day

Here:	0.070
State:	0.074

Complaint Deficiency

Exits that are free from obstructions and can be used at all times: Some (Minimal harm or potential for actual harm)

Make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves: Few (Minimal harm or potential for actual harm)

Portable fire extinguishers: Few (Minimal harm or potential for actual harm)

Provide housekeeping and maintenance services: Few (Minimal harm or potential for actual harm)

Exits that are free from obstructions and can be used at all times: Some (Minimal harm or potential for actual harm)

Have a program that investigates, controls and keeps infection from spreading: Some (Minimal harm or potential for actual harm)

Properly hold, secure and manage each resident's personal money which is deposited with the nursing home: Some (Potential for minimal harm)

Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function: Few (Minimal harm or potential for actual harm)

Exits that are accessible at all times: Few (Immediate jeopardy to resident health or safety)

Restrictions on the use of flammable curtains: Few (Minimal harm or potential for actual harm)

Keep accurate, complete and organized clinical records on each resident that meet professional standards: Some (Minimal harm or potential for actual harm)

Emergency lighting that can last at least 1 1/2 hours: Many (Potential for minimal harm)

A fire alarm system that can be heard throughout the facility: Many (Minimal harm or potential for actual harm)

Properly protected cooking facilities: Few (Minimal harm or potential for actual harm)

Proper medical gas storage and administration areas: Many (Potential for minimal harm)

Properly installed hallway dispensers for alcohol-based hand rub: Many (Minimal harm or potential for actual harm)

Make sure that special or therapeutic diets are ordered by the attending doctor: Some (Minimal harm or potential for actual harm)

Store, cook, and serve food in a safe and clean way: Some (Minimal harm or potential for actual harm)

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards: Some (Minimal harm or potential for actual harm)

Make sure each resident receives an accurate assessment by a qualified health professional: Few (Minimal harm or potential for actual harm)

Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured: Few (Minimal harm or potential for actual harm)

Make sure services provided by the nursing facility meet professional standards of quality: Some (Minimal harm or potential for actual harm)

Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible: Few (Minimal harm or potential for actual harm)

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards: Some (Minimal harm or potential for actual harm)

Have a program that investigates, controls and keeps infection from spreading: Some (Minimal harm or potential for actual harm)

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: Some (Minimal harm or potential for actual harm)

Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs: Some (Minimal harm or potential for actual harm)

Give or get quality lab services/tests in a timely manner to meet the needs of residents: Some (Minimal harm or potential for actual harm)

Keep accurate, complete and organized clinical records on each resident that meet professional standards: Some (Minimal harm or potential for actual harm)

Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour: Few (Minimal harm or potential for actual harm)

Properly working alarms on sprinkler valves: Many (Minimal harm or potential for actual harm)

Have an adequate water supply for the sprinkler system: Many (Minimal harm or potential for actual harm)

Weekly inspections and monthly testing of generators: Many (Minimal harm or potential for actual harm)

Other nearby hospitals and nursing homes

AMEDISYS HOME HEALTH OF NORTH HOUSTON (1.26 miles)
HEARTLAND HEALTH CARE CENTER AT WILLOWBROOK (0.95 miles)
KINETIC HEALTH CARE (1.83 miles)
METHODIST WILLOWBROOK HOSPITAL (0.30 miles)
PHOENIX HEALTHCARE SERVICES INC (1.15 miles)
WILLOWBROOK DIALYSIS (1.93 miles)

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