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Legend Oaks Healthcare And Rehabilitation - West S
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Ratings Deep Dive
5 Deficiencies found in last inspections
1 Penalties in last 3 years
1 Fines issued
| Citation | Date | Description | Severity |
|---|---|---|---|
| — | Dec 9, 2025 | Provide and implement an infection prevention and control program. | D |
| — | Oct 31, 2024 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D |
| — | Oct 31, 2024 | Ensure residents have reasonable access to and privacy in their use of communication methods. | F |
| — | Apr 12, 2024 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J |
| — | Apr 12, 2024 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D |
0.5 RN Hours / Resident / Day
3.5 Total Nurse Hours / Resident / Day
35.7% RN Turnover Rate
5.0 Long-Stay QM Rating
5.0 Short-Stay QM Rating
108.2 Avg Residents Per Day
| Measure | Score | Type |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | — | Long Stay |
| Percentage of long-stay residents who lose too much weight | — | Long Stay |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | — | Long Stay |
| Percentage of long-stay residents with a urinary tract infection | — | Long Stay |
| Percentage of long-stay residents who have depressive symptoms | — | Long Stay |
| Percentage of long-stay residents who were physically restrained | — | Long Stay |
| Percentage of long-stay residents experiencing one or more falls with major injury | — | Long Stay |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | — | Long Stay |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | — | Short Stay |
| Percentage of short-stay residents who newly received an antipsychotic medication | — | Short Stay |
Ownership & Compliance
Ownership Info
5% OR GREATER INDIRECT OWNERSHIP INTEREST DEWITT MEDICAL DISTRICT
OPERATIONAL/MANAGERIAL CONTROL BERTETTI HEALTHCARE, INC.
OPERATIONAL/MANAGERIAL CONTROL GRAY, ROBERT
OPERATIONAL/MANAGERIAL CONTROL MANSOOR, SAAD
CORPORATE OFFICER ALEXANDER, ALMA
CORPORATE OFFICER BURNAM, SOON
CORPORATE OFFICER KEETCH, CHAD
Recent Penalties
| Date | Type | Fine |
|---|---|---|
| Apr 12, 2024 | Fine | $8,632 |
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