Legend Oaks Healthcare And Rehabilitation Center Northwest Houston

Penalties

• Apr 23, 2024 — Fine ($39,045)

Inspection findings

1. Dec 1, 2025 Health · 6 findings
   • Not serious Scope/severity D Complaint

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Dec 12, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0694 Quality of Life and Care Deficiencies

     Provide for the safe, appropriate administration of IV fluids for a resident when needed.

     Corrected Dec 12, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0726 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.

     Corrected Dec 12, 2025 · CMS health inspection

   • Not serious Scope/severity C Complaint

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Dec 12, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Dec 12, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 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.

     Corrected Dec 12, 2025 · CMS health inspection

2. Jun 6, 2025 Health · 10 findings
   • Not serious Scope/severity E

     F0656 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.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0761 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.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Jun 12, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jun 6, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Jun 6, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jun 6, 2025 · CMS fire safety

3. Feb 28, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0656 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.

     Corrected Mar 3, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 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.

     Corrected Mar 3, 2025 · CMS health inspection

4. May 10, 2024 Health · 6 findings
   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected May 11, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected May 10, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected May 10, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected May 10, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected May 10, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected May 10, 2024 · CMS fire safety

5. Apr 23, 2024 Health · 2 findings
   • Serious Scope/severity K Complaint

     F0656 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.

     Corrected Apr 24, 2024 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Apr 24, 2024 · CMS health inspection

6. Mar 2, 2023 Health · 4 findings
   • Not serious Scope/severity E

     F0656 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.

     Corrected Mar 23, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Mar 23, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 23, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 1, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• ALI, NIDA — adp of the snf, NOT APPLICABLE, since 08/27/2019
• ALI, NIDA — operational/managerial control, NOT APPLICABLE, since 08/27/2019
• ALI, NIDA — managing control - governing body, NOT APPLICABLE, since 08/27/2019
• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 04/01/2017
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• STRATTON, CHARLES — corporate officer, NOT APPLICABLE, since 02/07/2005
• VINCENT, JAMES — operational/managerial control, NOT APPLICABLE, since 04/01/2017
• VINCENT, JAMES — managing control - governing body, NOT APPLICABLE, since 04/01/2017
• VINCENT, JAMES — adp of the snf, NOT APPLICABLE, since 04/01/2017
• ARMSTRONG HEALTHCARE, INC. — adp of the snf, NOT APPLICABLE, since 10/31/2025
• ARMSTRONG HEALTHCARE, INC. — operational/managerial control, NOT APPLICABLE, since 04/01/2017
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 05/01/2016
• LIBERTY COUNTY HOSPITAL DISTRICT NO 1 — 5% or greater direct ownership interest, 100%, since 04/01/2017
• NATIONAL HEALTH INVESTORS, INC. — adp of the snf, NOT APPLICABLE, since 04/01/2017
• TEXAS NHI INVESTORS, LLC — adp of the snf, NOT APPLICABLE, since 04/01/2017