LEGEND OAKS HEALTHCARE AND REHABILITATION - NORTH

11020 DESSAU RD
AUSTIN, TX, 78754
5128732244
CCN: 676238
2
Overall
2
Health
3
Staffing
4
Quality
ChainTHE ENSIGN GROUP
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
GUADALUPE COUNTY HOSPITAL BOARD5% OR GREATER DIRECT OWNERSHIP INTEREST100%
BURNAM, SOONCORPORATE OFFICERNOT APPLICABLE
GANN, KODYCORPORATE OFFICERNOT APPLICABLE
KEETCH, CHADCORPORATE OFFICERNOT APPLICABLE
RATHI, ANILOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
DESSAU HEALTHCARE INCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
QUINTERO, JOSELYNOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (1)
DateTypeAmount
2025-09-17Fine$42K
Health Deficiencies (28)
2025-09-17 · Health
D
F925 · Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
J
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
J
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2025-04-28 · Health
D
F573 · Resident Rights Deficiencies
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
2025-02-20 · Health
D
F919 · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
E
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
E
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2025-02-05 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2025-01-17 · Health
E
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2024-11-08 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2024-09-13 · Health
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2024-01-06 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2023-12-13 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
2022-10-16 · Health
D
F842 · 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.
E
F813 · Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
E
F803 · Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
D
F761 · 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.
E
F656 · 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.
D
F644 · Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
D
F637 · Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
E
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
J
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.12
3.68
RN Hrs/Resident/Day
0.61
0.54
LPN Hrs/Resident/Day
0.40
0.81
CNA Hrs/Resident/Day
2.11
2.33
PT Hrs/Resident/Day
0.12
0.12
Data as of 2026-03-01