Legend Oaks Healthcare and Rehabilitation Center -
8902 West Rd, Houston, TX 77064 · Harris County · 125 certified beds · avg 99 residents/day · certified since Apr 25, 2007
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Apr 23, 2024 · F-0656 · triggered by a complaint
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 24, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Apr 23, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 24, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (20)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 1, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Dec 1, 2025 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint |
| Dec 1, 2025 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Dec 1, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Dec 1, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Dec 1, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint |
| Jun 6, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 6, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 6, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 6, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jun 6, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jun 6, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 28, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Feb 28, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| May 10, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 23, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Apr 23, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 2, 2023 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 2, 2023 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Mar 2, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (1 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | E |
| 2024 | 3 | 2 | K ▲ |
| 2025 | 14 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $39,045.
| Date | Type | Amount / length |
|---|---|---|
| Apr 23, 2024 | Fine | $39,045 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.47 | 3.46 | 3.95 | top 38% in Texas; bottom 35% in the U.S. |
| Registered Nurse hours | 0.31 | 0.44 | 0.69 | bottom 31% in Texas; bottom 11% in the U.S. |
| Weekend total nurse staffing | 3.08 | 3.04 | 3.50 | top 36% in Texas; bottom 35% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.15 | 0.34 | 0.48 | bottom 9% in Texas; bottom 5% in the U.S. |
| Total nursing staff turnover (%) | 70.9 | 55.3 | 45.8 | bottom 18% in Texas; bottom 5% in the U.S. |
| RN turnover (%) | 70.0 | 54.6 | 42.9 | bottom 29% in Texas; bottom 12% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.32, RN 0.29, weekend 2.95. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Liberty County Hospital District No 1 | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/2017 |
| Ali, Nida | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/27/2019 |
| Ali, Nida | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/27/2019 |
| Ali, Nida | Individual | ADP of the SNF | NOT APPLICABLE | 08/27/2019 |
| Armstrong Healthcare, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Armstrong Healthcare, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 10/31/2025 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2017 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2016 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| National Health Investors, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2017 |
| Stratton, Charles | Individual | Corporate Officer | NOT APPLICABLE | 02/07/2005 |
| Texas Nhi Investors, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2017 |
| Vincent, James | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2017 |
| Vincent, James | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Vincent, James | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Who on your staff manages IV therapy, and what training and monitoring is in place?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Paradigm at Woodwind Lakes | 1.8 mi | Houston, TX | —/5 | SFF | |
| Fallbrook Rehabilitation and Care Center | 2.8 mi | Houston, TX | ★☆☆☆☆ | 1/5 | SFF |
| Park Manor of Cyfair | 2.8 mi | Houston, TX | ★★★★★ | 5/5 | |
| Misty Willow Healthcare and Rehabilitation Center | 4.3 mi | Houston, TX | ★☆☆☆☆ | 1/5 | abuseSFF |
| North Houston Transitional Care | 4.6 mi | Houston, TX | ★★★☆☆ | 3/5 | |
| Champions Healthcare at Willowbrook | 4.6 mi | Houston, TX | ★★☆☆☆ | 2/5 | abuse |
| Cypress Pointe Health & Wellness | 5.1 mi | Houston, TX | ★★★☆☆ | 3/5 | |
| Eagle Crest Rapid Recovery | 5.3 mi | Houston, TX | ★☆☆☆☆ | 1/5 | abuse |
| Houston Heights Nursing and Rehabilitation Center | 5.8 mi | Houston, TX | ★☆☆☆☆ | 2/5 | |
| Avir at Veterans Memorial | 6.1 mi | Houston, TX | ★☆☆☆☆ | 1/5 | abuse |
| Cypress Creek Rehabilitation and Healthcare Center | 6.1 mi | Cypress, TX | ★★☆☆☆ | 3/5 | |
| Avir at Arden Wood | 7.2 mi | Houston, TX | ★★☆☆☆ | 1/5 | SFF |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676137.