Legend Oaks Healthcare & Rehabilitation – North Houston

The state of Texas and Centers for Medicare and Medicaid Services (CMS) routinely investigate complaints and conduct surveys on nursing facilities to ensure the Homes are providing an acceptable standard of care. In the event of serious deficiencies and violations, the nursing home will be required to make immediate improvements that can be validated by state inspectors.

Any nursing home that fails to make necessary improvements or has recurring issues could be placed on the Special Focus Facility (SFF) list and kept under the watchful eye of the Medicare and Medicaid program. If the facility still fails to make the necessary changes, they may lose their contract with the federal and state governments to provide care to funded patients. In some cases, the nursing home must close their doors or sell or company to a facility in good standing in the nursing home industry.

Recently, Legend Oaks Healthcare and Rehabilitation – North Houston was designated a Special Focus Facility (SFF) by the Department of Health and Human Services. The Home was given the opportunity to make adjustments and corrections in the months ahead. However, they will likely not be removed from the list for at least a year or more while investigators, inspectors, and surveyors review medical records, make observations and conduct interviews to ensure that these changes are permanently protecting the health and well-being of all residents.

Legend Oaks Healthcare and Rehab – North Houston (SFF)

This 124-certified bed Medicaid/Medicare-participating nursing home provides cares and services to the residents of Houston and Harris County, Texas. The facility is located at:

12921 Misty Willow Dr.
Houston, TX 77070
(281) 469-7881

In addition to providing skilled nursing services, the facility also offers long-term rehabilitation, in-house therapy, and Alzheimer’s disease and dementia care.

Over $400,000 in Penalties

The Centers for Medicare and Medicaid Services and the state of Texas routinely conduct surveys and investigations to determine the level of care the nursing home provides. In the event of serious deficiencies and violations, the facility can receive multiple fines that are used to get the attention of the nursing home to make quick and lasting changes in the quality of care they provide every resident.

Over the last three years, Legend Oaks Healthcare and Rehabilitation – North Houston has received monetary fines on four occasions. These penalties includes a fine of $207,269 on August 24, 2016, and a $3263 fine on August 24, 2016. Two additional fines were issued against the facility including one totaling hundred $98,354 on January 12, 2017, and a $3291 fine on the same day. Additionally, Medicare denied payment for health services on August 24, 2016 for care provided to specific residents.

Current Nursing Home Resident Safety Concerns

Medicare and Medicaid use a star rating summary system to evaluate every nursing facility in the United States. Many families use this information to determine where to place a loved one who requires the highest level of care and their local community. The updated information is usually posted promptly on the federal Medicare.gov website and made available to the public.

Currently, Legend Oaks Healthcare and Rehabilitation – North Houston maintains an overall below-average two out of five stars rating compared although the facilities in the US. Their ranking includes one out of five stars for health inspections, four out of five stars for staffing, and three out of five stars for quality measures. Some of the major safety and health concerns involving this facility are listed below.

  • Failure to Immediately Tell the Resident’s Doctor or a Family Member the Resident’s Change of Condition That Resulted in the Resident’s Death

    In a summary statement of deficiencies dated February 3, 2017, the state investigator noted that the facility had failed “to consult with the physician when there was a significant change in the physical, mental or psychosocial status of [one resident at the facility].” This failure was evidenced by [the facility’s] failure to draw [the resident’s] STAT BMP (basic metabolic panel) for 10.5 hours.”

    The surveyor also noted that the facility “failed to consult [the resident’s doctor with] the critical potassium blood level for 5.25 hours.” This negligence resulted in the resident being “found unresponsive… and was pronounced dead 26 minutes after transfer to the hospital’s emergency room.”

    The deficiency was identified as an Immediate Jeopardy at the time, and when removed, “the facility remained out of compliance at the scope and pattern at the severity [that caused] actual harm due to the need to require more time to train the staff and monitor the plan of removal for effectiveness.”

    The failure “affected one former resident and placed 23 residents on the 200 Hallway in the facility at risk for the physicians not be consulted when they had a change in condition.” It was noted that this deficiency “could result in the delay of medical treatment, the development of new or worsening medical conditions, diminished quality of life, hospitalization and death.”

  • Failure to Protect a Resident from Abuse

    In a summary statement of deficiencies dated February 3, 2017, the state investigator noted that the facility failed to “ensure the right to be free from neglect.” This deficient practice affected two residents of the facility and was evidenced by the Home’s failure:

    • To draw the resident’s blood metabolic panel in a timely manner;
    • Notify the doctor of the critical potassium level in a timely manner;
    • To send the resident to the hospital before 14 hours after a nurse practitioner instructed them to do so;
    • Provide assessments and closely monitor the vital signs of the resident after they had changed; and
    • Not assessing the resident’s condition and vital signs during the night shift before the resident was found unresponsive.”

    It was noted the facility “failed to have adequate trained staff to evacuate [the resident] from the building in the event of an emergency.

  • Failure to Provide Care That Keeps or Builds a Resident’s Dignity and Respect of Individuality

    In a summary statement of deficiencies dated February 3, 2017, the state investigator noted the facility’s failure “to treating care in a manner and [in] an environment that promoted maintenance and enhanced [the] quality of life for [a resident] reviewed for care provided to promote dignity.” It was also noted that “the facility staff failed to provide timely incontinent care, bathing and personal care to [a resident who] did not have a shower for 37 days. She said she smelled herself and felt humiliated. She was angry, frustrated and felt like she was lied to. She was afraid that her wounds would become infected.”

    The investigator noted that “this affected one resident and placed the other 87 residents at risk for a loss of dignity, low self-esteem, and respect and full recognition of [their] individuality.” The resident’s medical records showed that she “required the extensive assistance of two or more persons for bed mobility and was totally dependent on two or more person to physical assist for transfer, locomotion on the unit and off the unit, dressing, toilet use, personal hygiene, and bathing.”

    The resident “was always incontinent of bowel and bladder. Further records review revealed the weight [of the patient as] 792 pounds and 64 inches in height [with a] risk of developing pressure sores and was not on a turning/repositioning program. She received an application for non-surgical dressing and ointment/medication other than to [her] feet.”

    The investigator reviewed the facility’s undated Statement of Resident Rights that read in part:

    “You have the right to all care necessary due to having the highest possible level of health, dignity, and respect. You have the right to live in a safe, decent, and clean conditions, be free from neglect, be treated with dignity, consideration, and respect. Make your own decisions regarding personal care.”

    The facility’s revised November 2007 policy and procedure titled: Incontinent Care states in part:

    • “It is the policy of this facility to remove urine and feces from the skin.
    • “It is the policy of this facility that residents are given appropriate treatment and services to maintain and improve his/her abilities.”
    • “Residents who are unable to carry out activities of daily living will receive necessary services to maintain: grooming, personal hygiene.”
  • Failure to Provide Adequate Nursing Staff Members to Care for Every Resident in a Way That Maximizes Their Well-Being

    In a summary statement of deficiencies dated February 3, 2017, the state investigator noted the facility’s failure “to ensure sufficient staffing to provide nursing-related services to attain and maintain the highest practicable physical, mental and psychosocial well-being for [a resident].” This deficiency was evidenced by the facility’s failure to “have sufficient staffing on the 10:00 PM through 6:00 AM shift to provide incontinent care for [a resident] and to evacuate her from the building in the event of an emergency.” The resident stated that she “was afraid when she was forgotten during an actual tornado alert.

  • Failure to Enforce Policies That Maintain the Well-Being of Every Resident

    In a summary statement of deficiencies dated February 3, 2017, the State surveyor noted the administration’s failure to “oversee the facility in a manner that enabled it to use the facility’s resources effectively to maintain the highest practicable physical well-being for [two residents at the facility].” This deficiency was evidenced by the Administrator “who was the Abuse Coordinator” and their failure “to ensure the facility’s policies and procedures were implemented for the prohibition of neglect.”

    It was also noted that the Administrator “failed to monitor the system of communication between nurses to follow-up with clinical laboratory results and doctor notification.” The Administrator also “failed to supervise and monitor the former Director of Nursing to ensure she carried out her responsibilities in the areas of assessment and monitoring of medical to conditions.” This failure included the “monitoring of vital signs when a resident had a change in condition including [a doctor] notification of follow-up timely [doctor] orders.”

    It was also noted that the Administrator had “failed to monitor the facility [to have] sufficient staff during the night shift to provide care for [a resident] which required 6 to 7 staff[members] to provide incontinent care.” This deficiency also included a failure to “make sure that all shifts were trained on how to evacuate a bariatric resident who had an oversized bed in the event of an emergency.”

  • Failure to Provide Every Resident Environment Free of Accident Hazards

    In a summary statement of deficiencies dated January 12, 2017, the state investigator noted the facility’s failure “to provide adequate supervision to prevent accidents for [a resident at the facility].” This deficiency was evidenced by the facility’s failure “to transfer [a resident] using two-person transfer, resulting in a fall with fractures to the resident’s both lower extremities, resulting in hospitalization.”

    The investigator noted that two nursing staff members placed the resident “back into bed after falling [and] did not notify nurse until the next day. These failures affected one resident [and] had the potential to place ten current residents on the 100 Hall (who required two-person transfers) at risk of physical harm, pain or hospitalization.”

    The state investigator reviewed the resident’s December 30, 2016, Incident Report that revealed on December 29, 2016, the resident “reported knee pain to the nurse. There was swelling. The nurse reported to the doctor who ordered an x-ray and pain medication.” The following day, the x-ray results “indicated it was a fracture of the left femur and right knee.”

    The investigation into the incident revealed that one staff member “attempted to transfer [the resident] into bed without help because she was unable to locate someone to help her.” That one staff member “was unable to transfer the resident had a lower the resident to the floormat. The Administrator stated, according to [the staff member] she looked in the hall for a nurse, but she was unable to find one and asked a Certified Nursing Assistant to help her.” The two staff members lifted the resident “back to bed.”

  • Failure to Ensure That Every Resident’s Drug Regiment Is Free from Unnecessary Medications

    In a summary statement of deficiencies dated January 12, 2017, the state investigator noted the facility’s failure “to ensure that every resident’s medication regimen was free from unnecessary medications without indications for its use.” This deficiency affected one resident “receiving antipsychotic medications on the 400 Hall [who was] at risk of receiving unnecessary medications, which could cause adverse side effects and a decline in health status.”

  • Failure to Develop, Implement and Enforce Programs That Investigate, Control and Keep Infections from Spreading

    In a summary statement of deficiencies dated May 4, 2017, the state investigator noted the facility’s failure “to maintain an effective infection control program to prevent the development and transmission of disease and infections.” The investigator noted that the “staff failed to perform properly. Care to [two residents]” and “failed to maintain proper infection control practices while performing wound care [on one of those residents].”

    The investigator also noted that there was “cross-contamination of the incontinent wipes container” when the staff “failed to maintain proper infection control practices while performing wound care on [another resident].”

Have You Been Injured, Neglected or Abused in a Texas Nursing Facility?

If you have suffered injuries or neglect, abuse or mistreatment while residing in a nursing facility, you are likely entitled to receive financial compensation for your damages. However, these cases tend to be highly complex and require the skills of a competent personal injury attorney specializes in abuse and neglect cases. A lawyer working on your behalf can file the necessary paperwork in the appropriate courthouse, gather evidence, speak to eyewitnesses, and build a case to ensure your family is compensated for your injuries.

These cases are typically handled through contingency fee arrangements. This agreement means that your attorney will begin the process of building and resolving your case without the need for any upfront payment. All legal services are paid only after the case is successfully concluded through a jury trial award or a negotiated out-of-court settlement. Get a free consultation, by completing the form here.

For information on Texas nursing home laws and resources, look here.


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