B
THE ARBOUR AT WESTMINSTER MANOR
78/100 score
0.58 hrs RN staffing
2 deficiencies
LEGEND OAKS HEALTHCARE AND REHABILITATION - NORTH
11020 DESSAU RD, AUSTIN, TX 78754
D
Facility Assessment
Inspectors recorded 3 citations at the actual-harm level or worse in the last three survey cycles.
At or above the 2024 benchmark — elevated deficiency count.
Quality Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
0.61 — At or above the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
28
Outstanding
0
Actual harm or worse (G–L)
3
|
|
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
|
Quality: ★★★★☆ (4/5)
Staffing: ★★★☆☆ (3/5)
|
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NursingHomeGrade Score
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46/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
3 immediate jeopardy issues found among 28 total deficiencies. 28 corrected.
Most recent inspection (September 17, 2025)
D
Potential harm — isolated
F0925
Status: Corrected
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected September 18, 2025
D
Potential harm — isolated
F0919
Status: Corrected
Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected February 21, 2025
J
Immediate jeopardy — isolated
F0600
Status: Corrected
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 — Deficient, Provider has date of correction, corrected September 18, 2025
J
Immediate jeopardy — isolated
F0607
Status: Corrected
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 18, 2025
D
Potential harm — isolated
F0609
Status: Corrected
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 18, 2025
D
Potential harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 18, 2025
E
Potential harm — pattern
F0677
Status: Corrected
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 21, 2025
D
Potential harm — isolated
F0573
Status: Corrected
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 28, 2025
E
Potential harm — pattern
F0550
Status: Corrected
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 21, 2025
Inspection cycle 2 (February 5, 2025)
E
Potential harm — pattern
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 6, 2025
E
Potential harm — pattern
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 11, 2024
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 14, 2023
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 6, 2025
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 14, 2024
D
Potential harm — isolated
F0695
Status: Corrected
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 14, 2023
E
Potential harm — pattern
F0580
Status: Corrected
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 — Deficient, Provider has date of correction, corrected January 20, 2025
E
Potential harm — pattern
F0558
Status: Corrected
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 14, 2024
Inspection cycle 3 (October 16, 2022)
J
Immediate jeopardy — isolated
F0600
Status: Corrected
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 — Deficient, Provider has date of correction, corrected November 28, 2022
E
Potential harm — pattern
F0609
Status: Corrected
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 28, 2022
E
Potential harm — pattern
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 7, 2024
E
Potential harm — pattern
F0803
Status: Corrected
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 — Deficient, Provider has date of correction, corrected November 28, 2022
E
Potential harm — pattern
F0813
Status: Corrected
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 28, 2022
D
Potential harm — isolated
F0761
Status: Corrected
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 — Deficient, Provider has date of correction, corrected November 28, 2022
D
Potential harm — isolated
F0637
Status: Corrected
Assess the resident when there is a significant change in condition
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 28, 2022
D
Potential harm — isolated
F0644
Status: Corrected
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 28, 2022
E
Potential harm — pattern
F0656
Status: Corrected
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 28, 2022
D
Potential harm — isolated
F0842
Status: Corrected
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 28, 2022
D
Potential harm — isolated
F0583
Status: Corrected
Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 28, 2022
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