Home › Texas › Travis County › Legend Oaks Healthcare and Rehabilitation - North
Legend Oaks Healthcare and Rehabilitation - North
11020 Dessau Rd, Austin, TX 78754 · CMS Certification Number (CCN) 676238
CMS abuse icon
CMS shows the abuse icon when a nursing home was cited for abuse or neglect at the harm level or above (scope/severity G or higher) on its most recent inspection cycle, or at the potential-harm level (D or higher) on both of its two most recent cycles. CMS data dictionary
At a glance
- CMS overall rating
- ★☆☆☆☆ 1 of 5
- Health inspection citations
- 24 in the last 3 inspection cycles (2 immediate jeopardy, 0 actual harm, 13 from complaints)
- Fire safety citations
- 0
- Fines (last 3 years)
- 1 fine, total $28,064
- Payment denials
- 0
- Most recent standard inspection
- April 23, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★☆☆☆☆ 1 of 5 | 2.7 | 3 |
| Health inspections | ★☆☆☆☆ 1 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★☆☆ 3 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | April 23, 2026 | 11 | 6 | 5 |
| Cycle 2 | February 20, 2025 | 11 | 3 | 8 |
CMS weighted health inspection score: 166.5 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: 1. How to read these citations
24 health citations across 10 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
April 23, 2026: 6 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/27/2026 |
| E | F-0803 | 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. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/27/2026 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/27/2026 |
| D | F-0687 | Provide appropriate foot care. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/27/2026 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/27/2026 |
| E | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/27/2026 |
September 17, 2025: 5 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/18/2025 |
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/18/2025 |
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/18/2025 |
| J | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/18/2025 |
| J | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/18/2025 |
April 28, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0573 | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/28/2025 |
February 20, 2025: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/21/2025 |
| E | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/21/2025 |
| E | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/21/2025 |
February 5, 2025: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/06/2025 |
| D | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/06/2025 |
January 17, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 01/20/2025 |
November 8, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/11/2024 |
September 13, 2024: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/14/2024 |
| E | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/14/2024 |
January 6, 2024: 1 citation (Complaint + Infection control)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint + Infection control | Deficient, Provider has date of correction Corrected 01/07/2024 |
December 13, 2023: 2 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/14/2023 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/14/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
No fire safety citations published for this facility in the CMS Fire Safety Deficiencies file.
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| September 17, 2025 | Fine | $28,064 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.17 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.66 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.41 | Not published | Not published |
| Nurse aide hours per resident per day | 2.1 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.68 | Not published | Not published |
| RN hours per resident per day, weekends | 0.49 | Not published | Not published |
| Total nursing staff turnover (%) | Staffing data did not meet the criteria required to calculate a turnover measure. | 55.3 | 45.8 |
| Registered nurse turnover (%) | Staffing data did not meet the criteria required to calculate a turnover measure. | Not published | Not published |
| Administrators who have left | Staffing data did not meet the criteria required to calculate a turnover measure. | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Guadalupe County Hospital Board
- Ownership type
- For profit - Limited Liability company
- Chain
- The Ensign Group (344 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 124
- Average residents per day
- 109.9
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- October 20, 2009
- County/parish
- Travis
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
15 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| GUADALUPE COUNTY HOSPITAL BOARD | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| QUINTERO, JOSELYN | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| RATHI, ANIL | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BURNAM, SOON | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GANN, KODY | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KEETCH, CHAD | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| DESSAU HEALTHCARE INC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| QUINTERO, JOSELYN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| RATHI, ANIL | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| DESSAU HEALTHCARE INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ENSIGN SERVICES INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| NATIONAL HEALTH INVESTORS, INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| TEXAS NHI INVESTORS, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| QUINTERO, JOSELYN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| RATHI, ANIL | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Legend Oaks Healthcare and Rehabilitation - North. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.