01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-06-06 | 12 | 2025-06-06 | 4 |
| Cycle 2 | 2024-05-10 | 3 | 2024-05-10 | 5 |
| Cycle 3 | 2023-03-02 | 5 | 2023-03-02 | 1 |
CMS CCN 6761372026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Legend Oaks Healthcare And Rehabilitation Center -
8902 West Rd · Houston, TX 77064 · Harris County
Certified beds125CMS provider file
Recent citation rows30current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
30 rows in the current release
2 rows carry G–L scope/severity codes; 2 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-01 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-12-12 · complaint2025-12-01 · HEALTHF0694Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-12-12 · complaint2025-12-01 · HEALTHF0726Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-12-12 · complaint2025-12-01 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2025-12-12 · complaint2025-12-01 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-12-12 · complaint2025-12-01 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-12-12 · complaint2025-06-06 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-06-06 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-06-06 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-06-06 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-06-06 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-06-06 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-06-06 · FIREK0351Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-06-06 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-06-06 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-06-06 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-02-28 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-03-03 · complaint2025-02-28 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-03-03 · complaint2024-05-10 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-05-112024-05-10 · FIREK0293Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-05-10 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-05-10 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-05-10 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-05-10 · FIREK0741Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2024-05-1003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-04-23 | Fine | $39,045 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LIBERTY COUNTY HOSPITAL DISTRICT NO 1Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/01/2017
- ALI, NIDAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/27/2019
- VINCENT, JAMESIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2017
- BURNAM, SOONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2017
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2011
- STRATTON, CHARLESIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/07/2005
- ARMSTRONG HEALTHCARE, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2017
- ALI, NIDAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/27/2019
- VINCENT, JAMESIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2017
- ARMSTRONG HEALTHCARE, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 10/31/2025
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2016
- NATIONAL HEALTH INVESTORS, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 04/01/2017
- TEXAS NHI INVESTORS, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/01/2017
- ALI, NIDAIndividual · ADP OF THE SNFNOT APPLICABLE · since 08/27/2019
- VINCENT, JAMESIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/01/2017
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.32per resident day
RN hours0.29per resident day
Weekend nurse hours2.95per resident day
Staff turnover70.9%CMS reported field
06 / LOCAL RECORDS
Open the Houston ledger →Other published facilities nearby
Afton Oaks Nursing And Rehabilitation Center169 beds · CMS overall 1/544 citation rowsAshford Gardens202 beds · CMS overall 2/537 citation rowsAvir At Arden Wood174 beds · CMS overall 2/550 citation rowsAvir At Courtyard120 beds · CMS overall 4/526 citation rowsAvir At Golfcrest200 beds · CMS overall 2/532 citation rowsAvir At Houston148 beds · CMS overall 1/551 citation rowsAvir At Orem120 beds · CMS overall 4/537 citation rowsAvir At Veterans Memorial120 beds · CMS overall 1/538 citation rows