Legend Oaks Healthcare And Rehabilitation Center

Legend Oaks Healthcare And Rehabilitation Center was recognized and ceritified in 2007 by Centers for Medicare & Medicaid Services as one of model nursing home providers promoting health and improving quality of life. Legend Oaks Healthcare And Rehabilitation Center which is located in 8902 West Rd Houston, is scientifically measured and assessed by Centers for Medicare & Medicaid Services and is shown to provide good nursing home services or products under the Medicare program. Legend Oaks Healthcare And Rehabilitation Center is being offered ceritified services and products in Texas.
Address:   8902 West Rd
       Houston, TX 77064

Phone:   (713) 849-0990

County: Harris
Federal Provider Number: 676137
Participates in: Medicare And Medicaid
Certified Date: Wednesday, April 25, 2007 (18 years certified)
Certified Agency: Centers for Medicare & Medicaid Services
Legal Business Name: Pend Oreille River Associates, Llc
Ownership Type: For Profit - Corporation
Provider Changed Ownership in Last 12 Months: No



TypeNameRole Description
OrganizationThe Doug Preston Family Trust Of 2006 F/b/o Preston Andrew LorchGeneral Partnership Interest
OrganizationThe Doug Preston Family Trust Of 2006 F/b/o Megan Elizabeth LorchGeneral Partnership Interest
OrganizationThe Doug Preston Family Trust Of 2006 F/b/o Joye Lynn BinkleyGeneral Partnership Interest
OrganizationThe Doug Preston Family Trust Of 2006 F/b/o John David PrestonGeneral Partnership Interest
OrganizationThe Doug Preston Family Trust Of 2006 F/b/o Douglas Matthew PrestonGeneral Partnership Interest
OrganizationThe Doug Preston Family Trust Of 2006 F/b/o Carole Elizabeth LarkinGeneral Partnership Interest
OrganizationTas Consulting Inc5% Or More Ownership Interest
OrganizationThe Doug Preston Family Trust Of 2006 F/b/o Benjamin Matthew PrestonGeneral Partnership Interest
OrganizationPend Oreille River Associates, Llc5% Or More Ownership Interest
OrganizationLgd Management LpOperational/managerial Control
OrganizationLgd Management Gp, IncGeneral Partnership Interest
OrganizationKatherine Zinicola Trust Of 2007General Partnership Interest
OrganizationGoldstraw Management, Llc5% Or More Ownership Interest
OrganizationGoldstraw Investments, Ltd5% Or More Ownership Interest
OrganizationDoug And Suzanne Preston Management Company, LlcGeneral Partnership Interest
OrganizationDoug And Suzanne Preston Investments LtdGeneral Partnership Interest
OrganizationDaniel Glen Trust Of 2007General Partnership Interest
OrganizationCynthia Glen Trust Of 2007General Partnership Interest
OrganizationCreative Health Capital, LlcGeneral Partnership Interest
OrganizationCraigmillar Glen LlcGeneral Partnership Interest
OrganizationAllesandra Zinicola Trust Of 2007General Partnership Interest
OrganizationThe Doug Preston Family Trust Of 2006 F/b/o Raymond Sidney PrestonGeneral Partnership Interest
OrganizationThe Doug Preston Family Trust Of 2006 F/b/o Sara Nicole PrestonGeneral Partnership Interest
OrganizationThe Doug Preston Family Trust Of 2006 F/b/o Sheila Gay PrestonGeneral Partnership Interest
OrganizationThe Doug Preston Family Trust Of 2006 F/b/o Wayne Glenn PrestonGeneral Partnership Interest
OrganizationThe Tomerlin Childrens Trust Of 2006 F/b/o John Hunter Tomerlin5% Or More Ownership Interest
OrganizationThe Tomerlin Childrens Trust Of 2006 F/b/o Mary Elizabeth Tomerlin5% Or More Ownership Interest
OrganizationThe Tomerlin Childrens Trust Of 2006 F/b/o Timothy Henry Tomerlin5% Or More Ownership Interest
OrganizationThe Wind River Associates, LlcGeneral Partnership Interest
OrganizationTomerlin Family Partnership, Ltd5% Or More Ownership Interest
OrganizationTomerlin Management, Llc5% Or More Ownership Interest
PersonWendy Tomerlin5% Or More Ownership Interest
PersonThomas TomerlinDirector/officer
PersonThomas Tomerlin5% Or More Ownership Interest
PersonLeslie TaylorW-2 Managing Employee
PersonTimothy Sullivan5% Or More Ownership Interest
PersonDavid SheffieldGeneral Partnership Interest
PersonLee RivazW-2 Managing Employee
PersonSuzanne PrestonGeneral Partnership Interest
PersonClinton PrestonGeneral Partnership Interest
PersonClinton PrestonDirector/officer
PersonClinton Preston5% Or More Ownership Interest
PersonDwight MuseDirector/officer
PersonDwight Muse5% Or More Ownership Interest
PersonLaura MillerGeneral Partnership Interest
PersonDenise HelmsGeneral Partnership Interest
PersonRocio GonzalezGeneral Partnership Interest
PersonLaura Goldstraw5% Or More Ownership Interest
PersonChristopher GoldstrawDirector/officer
PersonChristopher Goldstraw5% Or More Ownership Interest
PersonEula EdwardsW-2 Managing Employee
PersonDaniel Brown5% Or More Ownership Interest
PersonBarbara Brown5% Or More Ownership Interest

Provider Resides in Hospital: No
Number of Federally Certified Beds: 125
Number of Residents in Federally Certified Beds: 102 (82% occupied)
Continuing Care Retirement Community: No
Special Focus Facility: No
With a Resident and Family Council: Both
Automatic Sprinkler Systems in All Required Areas: Yes


Survey Date: Wednesday, June 18, 2014
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, July 14, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0332 (Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Monday, July 14, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Fire Safety
Deficiency: K0066 (Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, June 23, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0241 (Provide care for residents in a way that maintains or improves their dignity and respect in full rec)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Thursday, July 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Monday, July 14, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0502 (Give or get quality laboratory services/tests in a timely manner to meet the needs of residents.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Monday, June 23, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0514 (Keep accurate, complete and organized clinical records on each resident that meet professional stand)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Monday, July 14, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, June 19, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0469 (Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Monday, July 14, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0505 (Quickly tell the resident's doctor the results of laboratory tests.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Monday, June 23, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0246 (Reasonably accommodate the needs and preferences of each resident.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Monday, July 14, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Fire Safety
Deficiency: K0144 (Weekly inspections and monthly testing of generators.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, July 2, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Monday, July 14, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0517 (Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missi)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Wednesday, July 16, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0328 (Properly care for residents needing special services, including: injections, colostomy, ureostomy, i)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Saturday, July 19, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Friday, July 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0507 (Keep complete, dated laboratory records in the resident's file.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Monday, June 23, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Fire Safety
Deficiency: K0064 (Portable fire extinguishers.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, July 2, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Monday, June 23, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 18, 2014
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Monday, July 14, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, March 6, 2014
Survey Type: Health
Deficiency: F0493 (Establish a governing body that is legally responsible for establishing and implementing policies fo)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, April 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, October 22, 2013
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 5, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0490 (Make sure that the facility is administered in an acceptable way that maintains the well-being of ea)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0241 (Provide care for residents in a way that maintains or improves their dignity and respect in full rec)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0312 (Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0332 (Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0328 (Properly care for residents needing special services, including: injections, colostomy, ureostomy, i)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0500 (Employ or obtain outside professional resources to provide services in the nursing home when the fac)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0252 (Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal be)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0333 (Ensure that residents are safe from serious medication errors.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0225 (1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) rep)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0514 (Keep accurate, complete and organized clinical records on each resident that meet professional stand)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0505 (Quickly tell the resident's doctor the results of laboratory tests.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, July 26, 2013
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, July 24, 2013
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, July 24, 2013
Survey Type: Fire Safety
Deficiency: K0066 (Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, July 24, 2013
Survey Type: Fire Safety
Deficiency: K0067 (Heating and ventilation systems that have been properly installed according to the manufacturer's in)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, July 24, 2013
Survey Type: Fire Safety
Deficiency: K0211 (Properly installed hallway dispensers for alcohol-based hand rub.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, July 24, 2013
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, July 24, 2013
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, July 24, 2013
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, May 15, 2013
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, June 4, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, March 5, 2013
Survey Type: Health
Deficiency: F0225 (1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) rep)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, March 7, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, March 5, 2013
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, March 19, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)

Survey Date: Wednesday, October 17, 2012
Survey Type: Health
Deficiency: F0456 (Keep all essential equipment working safely.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 2, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)

Survey Date: Wednesday, October 17, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 2, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Health
Deficiency: F0318 (Ensure that residents with limited range of motion receive appropriate treatment and services to inc)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 27, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Health
Deficiency: F0248 (Provide activities to meet the interests and needs of each resident.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 27, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 27, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 27, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 27, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Fire Safety
Deficiency: K0056 (An approved automatic sprinkler system connected to the fire alarm system.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 18, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Health
Deficiency: F0514 (Keep accurate, complete and organized clinical records on each resident that meet professional stand)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 27, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 27, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 18, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 27, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 27, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 18, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Health
Deficiency: F0241 (Provide care for residents in a way that maintains or improves their dignity and respect in full rec)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 27, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Fire Safety
Deficiency: K0051 (A fire alarm system that can be heard throughout the facility.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 18, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Health
Deficiency: F0278 (Ensure each resident receives an accurate assessment by a qualified health professional.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 27, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 27, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 30, 2012
Survey Type: Health
Deficiency: F0312 (Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 27, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, May 25, 2012
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, June 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Friday, May 25, 2012
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, June 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Friday, May 25, 2012
Survey Type: Health
Deficiency: F0498 (Make sure that nurse aides show they have the skills and techniques to be able to care for residents)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, June 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Friday, May 25, 2012
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, June 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, May 1, 2012
Survey Type: Health
Deficiency: F0327 (Give each resident enough fluids to keep them healthy and prevent dehydration.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 15, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, May 1, 2012
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 15, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Wednesday, March 14, 2012
Survey Type: Health
Deficiency: F0226 (Develop and implement policies for 1) screening and training employees; and the 2) prevention, ident)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, March 28, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Wednesday, March 14, 2012
Survey Type: Health
Deficiency: F0328 (Properly care for residents needing special services, including: injections, colostomy, ureostomy, i)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, March 28, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Wednesday, March 14, 2012
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, March 28, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Wednesday, January 4, 2012
Survey Type: Health
Deficiency: F0155 (Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directive)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, January 11, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Number of Facility Reported Incidents: 2
Number of Substantiated Complaints: 10
Number of Fines: 1
Number of Payment Denials: 2
Total Number of Penalties: 3
Total Amount of Fines in Dollars: USD 2,173


Date of inspection that triggered the penalty: Friday, May 25, 2012
Penalty Type: Fine
Fine Amount: 2,173

Date of inspection that triggered the penalty: Thursday, August 30, 2012
Penalty Type: Payment Denial
Date on which Medicare/Medicaid payment for new admissions was suspended: Friday, September 28, 2012
Number of days for which Medicare/Medicaid payment was suspended: 2

Date of inspection that triggered the penalty: Wednesday, June 18, 2014
Penalty Type: Payment Denial
Date on which Medicare/Medicaid payment for new admissions was suspended: Thursday, July 17, 2014
Number of days for which Medicare/Medicaid payment was suspended: 2
This data allows consumers to compare information about nursing homes. Information here is not an endorsement or advertisement for any nursing home and should be considered carefully. Use it with other information you gather about nursing homes facilities. Talk to your doctor or other health care provider about this.



This data was updated by using data source from Centers for Medicare and Medicaid Services (CMS) which is publicized on Wednesday, October 1, 2014. If you found out that something incorrect and want to change it, please follow this Update Data guide.

The Five Star Quality Rating System is not a substitute for visiting the nursing home. This system can give you important information, help you compare nursing homes by topics you consider most important, and help you think of questions to ask when you visit the nursing home. Use the Five-Star ratings together with other sources of information.

items rating
Health Inspection Rating (1 out of 5 stars)
Quality Rating (3 out of 5 stars)
Staffing Rating (3 out of 5 stars)
RN Staffing Rating (3 out of 5 stars)
Overall Rating (1 out of 5 stars)
Nursing homes vary in the quality of care and services they provide to their residents. Reviewing health inspection results, staffing data, and quality measure data are three important ways to measure nursing home quality. This information gives you a "snap shot" of the care individual nursing home give.


Patients experiences Provider State Nation
Percent of High Risk Long Stay Residents With Pressure Ulcers
N/A
7%
6%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
N/A
3%
3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain
N/A
9%
8%
Percent of Long Stay Residents Who Were Physically Restrained
N/A
1%
1%
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased
N/A
20%
16%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder
N/A
3%
3%
Percent of Long Stay Residents With a Urinary Tract Infection
N/A
7%
6%
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain
N/A
19%
19%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened
N/A
1%
1%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
89%
94%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
91%
94%
Percent of Long Stay Residents Who Have Depressive Symptoms
N/A
8%
6%
Percent of Long Stay Residents Who Lose Too Much Weight
N/A
6%
7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication
N/A
26%
20%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder
N/A
44%
44%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
73%
83%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication
N/A
4%
2%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
75%
84%

N/A
Data not available.

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Legend Oaks Healthcare And Rehabilitation Center [Federal No:676137] near 8902 West Rd, Houston TX

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