LEGEND OAKS HEALTHCARE AND REHABILITATION - NORTH/ (HOUSTON, TX) Detailed Nursing Home Profile

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.670
Texas:	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
State:	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

Quality Measures

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

Here:	13.5%
Texas:	20.4%

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

Here:	13.1%
Texas:	11.4%

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

This Nursing Home:	16.7%
Texas:	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

This Nursing Home:	3.5%
State:	3.9%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	14.3%
Texas:	8.3%

Percent of long-stay residents who have depressive symptoms

Here:	6.7%
Texas:	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

This Nursing Home:	11.2%
Texas:	20.2%

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

Here:	96.5%
Texas:	76.2%

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

Here:	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%

Complaint Deficiency

Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Portable fire extinguishers
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
- Harm: Potential for minimal harm
- Scope: Some
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
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Restrictions on the use of flammable curtains
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Emergency lighting that can last at least 1 1/2 hours
- Harm: Potential for minimal harm
- Scope: Many
A fire alarm system that can be heard throughout the facility
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- Harm: Potential for minimal harm
- Scope: Many
Properly installed hallway dispensers for alcohol-based hand rub
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Make sure that special or therapeutic diets are ordered by the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure each resident receives an accurate assessment by a qualified health professional
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Give or get quality lab services/tests in a timely manner to meet the needs of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly working alarms on sprinkler valves
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Have an adequate water supply for the sprinkler system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many

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

Staff Information

Quality Measures

Complaint Deficiency

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