Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legend Oaks Healthcare And Rehabilitation Center - during CMS and state inspections, most recent first.
Call Light Not Within Reach: A resident with dementia, generalized weakness, and a right below-the-knee amputation had a care plan directing staff to keep the call light within reach due to ADL deficits and fall risk. During observation, the call light was found on top of a chair behind the resident’s line of sight, with furniture blocking access, and the resident stated he did not know where it was. The DON and DOR acknowledged the call light should have been placed within reach.
Failure to Release Resident Records to Authorized Representative: A resident with severe cognitive impairment and a family member identified in the admission paperwork as her representative had records requested after discharge, including incident-related documents and the full medical record. The family member said he requested the records by letter and phone, but the DON, ADM, and medical records staff required a POA before release and did not provide the records as requested, despite facility policy stating a resident may authorize release of personal and clinical records and that a release form is needed when family requests records.
Failure to Protect Resident Record Privacy: An OTA left an open laptop unattended in the rehab gym with protected resident information visible from the hallway. The surveyor observed the laptop on a table near a window with no staff present, and the OTA later stated she had stepped away for a minute and should not have left the screen open because it exposed PHI. The DON stated the laptop should have been locked or closed to protect resident privacy and avoid a HIPAA violation.
Oxygen Storage Room Obstructed and Cylinders Improperly Stored: The facility failed to keep the oxygen storage room on Hall 400 free of hazards when a full O2 cylinder on a stand was placed behind the door and multiple empty oxygen stands cluttered the entrance. The DON observed that the door hit the cylinder when opened, the room was difficult to enter, and a full cylinder was stored with the empty cylinders instead of being separated as required by policy.
Failure to provide ordered puree diet. A resident with dysphagia and swallowing problems was ordered a puree texture diet with thin liquids, but his dinner tray included 2 sugar cookies. He ate part of the cookies and began coughing until an LVN gave him water. The LVN said she checked the tray but did not notice the cookies, and the DON confirmed the resident should not have received them.
Survey Results Not Available for Resident Review: The facility failed to keep the most recent survey results in the lobby survey binder for resident and family review. Observation showed the binder contained older survey results, and the ADM confirmed the December survey results were not included. The facility policy reviewed did not include language about residents’ right to access the most recent survey results.
Expired Glucerna 1.2 enteral feedings were found stored in the nutrition room during survey observation. The DON stated the feedings were expired, that staff should have removed them, and that the facility did not have a policy on expired enteral feedings. The DON also stated there were no residents currently receiving Glucerna 1.2, but acknowledged nursing staff could potentially grab the wrong feeding and give it to the wrong resident.
Inadequate perineal care during incontinence care: two residents received incomplete hygiene during observed CNA care. A female resident with dementia and total bowel/bladder incontinence was cleaned without the labia being separated and without cleaning the pubic area, and a male resident with a urinary catheter and bowel incontinence was cleaned without the pubic area being washed. Both CNAs acknowledged the missed care, and the DON confirmed the pubic area should have been cleaned.
Failure to obtain self-administration order for nasal medication: A resident with intact cognition and orders for daily Fluticasone nasal spray was observed self-administering the medication after an MA handed it to him. There was no care plan or physician order for self-administration, and the DON stated the IDT should have assessed the resident’s ability and obtained the required order.
Unattended Computer Displayed Resident PHI: An LVN left a cart computer open and unattended with a resident’s eMAR visible, including the resident’s face photo, DOB, and medications, while entering the room to check blood sugar. The LVN acknowledged the privacy violation, and the DON stated the nurse should have closed or logged off the computer to protect the resident’s personal and medical information.
MDS assessments were coded incorrectly for PASRR status for a resident with schizophrenia, bipolar disorder, and intellectual/developmental disability diagnoses. The admission and Significant Change MDS both marked PASRR as no, even though the resident’s PASRR screening and evaluation showed positive findings and the care plan identified PASRR positive with habilitation coordination. The MDS Nurse stated the assessments should have been coded yes, and the DON stated accurate coding was needed to trigger needed services.
Medication Error Rate Exceeded Threshold: Surveyors found a 7.41% medication error rate based on two errors in 27 opportunities. One resident with COPD, HTN, and colon cancer received Fluticasone nasal spray incorrectly when an MA allowed the resident to self-administer two sprays in each nostril instead of the ordered one spray per nostril. Another resident with CVA, chronic respiratory failure, malnutrition, and DM2 received only 15 ml of Enulose instead of the ordered 30 ml twice daily. The DON confirmed both events were medication errors.
Two residents receiving insulin had pens stored in a nursing cart without open dates. One resident had insulin Degludec with a box instruction to store at room temperature for up to 56 days after first use, and the other had insulin Glargine-yfgn with a discard-after-28-days instruction. An LVN stated staff did not know when the pens had been opened or when they should be discarded because the open dates were missing, and the DON said nurses were responsible for writing open dates on insulins when opened.
Unsafe Puree Diet Preparation: A dietary staff member was observed preparing pureed pork loin using unsanitary handling practices, including taking a measuring cup from a counter with liquid droplets, placing it into the pork loin to collect broth, and using it repeatedly while pureeing. The staff member and DS both stated the actions created cross contamination concerns, and the facility policy required utensils and cups to be handled to avoid contact with contaminated surfaces.
Incomplete documentation of oxygen administration was found for a resident with DM2, malnutrition, HF, and PVD who had severe cognitive impairment and was receiving O2 via NC. The MAR was left blank for several days even though an LVN stated nurses administered the ordered O2, and the DON acknowledged the missing documentation; the facility policy required documenting all appropriate information in the medical record for oxygen therapy.
The facility failed to include the use of bed rails in the care plans for three residents, despite their medical conditions and cognitive impairments. Observations confirmed the consistent use of bed rails without documentation in the care plans, and the DON acknowledged the requirement for physician orders, consent, and care plan inclusion, which was not met.
The facility failed to assess and document the use of bed rails for three residents, leading to a deficiency in care. Residents with severe impairments were not evaluated for alternatives or risks of entrapment before bed rails were installed. Observations showed residents with bed rails up, and necessary documentation and care planning were inadequate.
The facility failed to store and handle food according to professional standards, with an opened bag of cheese and unsealed cooked pork found in the cooler, both lacking proper sealing and labeling. Additionally, a mop was improperly stored, preventing air drying. These actions were contrary to the facility's policies based on the Texas Food Establishment Rules and the U.S. Public Health Service Food Code.
A facility failed to properly document a resident's DNR order, leading to potential risk of unwanted CPR. The resident's DNR was incomplete, lacking necessary signatures, and the social worker was unaware of its status. The resident's responsible party did not complete the DNR form and was concerned about a forged signature. Facility policy on advance directives was not followed.
Two residents with indwelling urinary catheters received inadequate care, risking urinary tract infections. One resident's catheter bag was not properly managed, while another received improper cleaning, leading to a UTI diagnosis. Both CNAs had completed training but failed to follow procedures.
The facility failed to maintain proper communication and documentation for two residents requiring dialysis. For one resident, forms were incomplete, missing signatures, and lacked confirmation of communicated information. Another resident's forms were incomplete, and a missed dialysis session was not properly documented. The facility did not adhere to its policy for ongoing communication with the dialysis facility, risking inadequate care.
A facility failed to coordinate hospice care and maintain proper documentation for a resident receiving hospice services. The resident's plan of care, DNR, and hospice physician orders were not available in the hospice binder or electronic medical record. Interviews revealed that the DON and SW were unaware of the location of these documents, risking inadequate end-of-life care. The facility's policy requires individualized care plans and collaboration with hospice, which was not followed.
The facility failed to maintain proper infection control practices for two residents with indwelling urinary catheters. In one case, a CNA did not perform hand hygiene after glove removal during catheter care, risking cross-contamination. In another case, a resident's catheter tubing was found touching the floor, and staff did not use enhanced barrier precautions as required. These lapses were acknowledged by the DON and could increase infection risk.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure Resident #3’s call light was within reach so he could ask for help as needed. Resident #3 was admitted with diagnoses including unspecified dementia, generalized weakness, and a below-the-knee amputation of the right lower extremity. His admission MDS showed a BIMS score of 9 out of 15, reflecting moderate cognitive impairment, and he required partial/moderate assistance to total assistance with ADLs. His care plan identified ADL self-care performance deficits related to generalized weakness, gait/balance problems, and the right lower extremity amputation, and noted he was at risk for falls. One intervention directed staff to anticipate needs and make sure the call light was within reach and to encourage him to use it for assistance as needed. During observation, Resident #3 was lying in bed with quarter side rails up on both sides. The call light was observed placed on top of a chair next to his bed, behind his line of sight, with the bedside table pushed over the chair and a wheelchair in front of the bedside table. Resident #3 stated he would use the call button to call staff for help but did not know where it was. The DON stated the call light was on top of the chair and staff probably did not put it back on the bed, and that staff should make sure it was within Resident #3’s reach. The DOR stated rehabilitation staff should ensure the call light was within reach after providing services in the resident’s room. The facility policy stated the call device should be placed within the resident’s reach before leaving the room.
Failure to Release Resident Records to Authorized Representative
Penalty
Summary
The facility failed to treat the decisions of a resident representative as the decisions of the resident to the extent delegated by the resident for one resident whose records were reviewed. The resident had been admitted with diagnoses including orthostatic hypotension, a personal history of malignant neoplasm of the breast, and acquired absence of the right breast and nipple. Her MDS assessment showed a BIMS score of 5 out of 15, reflecting severe cognitive impairment, and participation in assessment and goal setting included the resident and a family member. Her admission paperwork identified a family member as the representative and emergency contact, and the resident preferred that family member to sign the disclosure authorization. After the resident was discharged, the family member requested copies of records related to an incident, including incident reports, nursing and clinical notes, staff names and titles, facility policies, internal documentation, and CT scan results. The family member stated he also requested the resident’s medical records by letter and by telephone. The facility responded that it could provide copies of the resident’s medical records only after receiving a completed medical records authorization from the legally authorized representative, and staff told the family member that a POA would be needed before records could be released. The DON stated the family member had requested the resident’s entire medical record but would not provide a POA, and corporate advised that the records could only be released if a POA was provided. The medical records staff stated she could release records with an authorization for release of medical records and that legal would verify POA status, but she also followed facility protocol. The administrator stated he had been advised by the legal team that records could only be released to the family member upon provision of a POA, and the facility policy stated that a resident may authorize release of personal and clinical records as provided by law and that if records are requested by family, a medical records release form must be completed.
Failure to Protect Resident Record Privacy
Penalty
Summary
The facility failed to respect a resident’s right to personal privacy and confidentiality of personal and medical records when an OTA left an open laptop unattended in the rehabilitation gym. During observation, the laptop was sitting on a table in front of a window exposed to the hallway, with no staff in sight, and anyone walking down the hall would have been able to view the screen. When the surveyor entered the gym and called out, the OTA came out of a back office and stated the laptop was hers and that she had stepped away for a minute but should not have left the screen open because it revealed protected resident information. During interview, the OTA stated that leaving the screen open was a HIPAA violation if anyone else read the information on the screen. The DON later stated that if the OTA was working on a resident’s file, she should have secured it by locking or closing the laptop to ensure the resident’s privacy, and that if anyone else read the resident information it would be a HIPAA violation and the resident’s information could be compromised. The facility policy reviewed stated that residents have rights and protections under federal and state law and that clinical records and personal information shall be maintained private by staff.
Oxygen Storage Room Obstructed and Cylinders Not Properly Separated
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible in 1 of 4 halls observed for a safe environment, specifically the oxygen storage room on Hall 400. During observation and interview, the DON opened the oxygen room door and it immediately struck a full oxygen cylinder on a stand that had been placed behind the door. Multiple empty oxygen stands were also observed on the left side of the room, further obstructing the entrance and limiting the ability to walk freely into the storage area. Even after moving items, there was minimal space to enter the room. Observation also showed a full oxygen cylinder stored on the side where empty oxygen cylinders were kept, with an empty sign posted above the empty cylinders. The DON stated the full cylinder behind the door should not have been there because staff could knock it over onto other full cylinders, and she stated the room was cluttered with empty oxygen stands upon opening the doors. She further stated staff could have difficulty retrieving an oxygen cylinder and could delay providing oxygen to a resident as needed. Review of the facility policy stated that oxygen tanks must be stored safely, secured to a wall within a chain or heavy cable, and that full tanks must be separated from empty tanks and identified as such.
Failure to Provide Ordered Puree Diet
Penalty
Summary
The facility failed to ensure that Resident #2 received food prepared in the puree form ordered for him. Resident #2 was admitted with dysphagia following a cerebral infarction and had a BIMS score of 12, with documented swallowing problems including holding food in his mouth or cheeks, coughing or choking during meals or when swallowing medications, and complaints of difficulty or pain when swallowing. His care plan directed staff to provide and serve the diet as ordered, and his physician orders specified an LCS/Renal diet with puree texture and thin liquids. During the dinner meal, Resident #2 was served his tray in puree texture but also received 2 sugar cookies. He opened the package, took a couple of bites, and started coughing. An LVN provided water and the coughing stopped. The LVN stated she checked meal trays for residents eating in their rooms, including Resident #2's tray, but did not notice the cookies. The DON confirmed that Resident #2 should not have received the cookies because he was on a puree diet and had dysphagia.
Survey Results Not Available for Resident Review
Penalty
Summary
The facility failed to ensure residents were able to examine the results of the most recent survey conducted by Federal or State surveyors and any plan of correction in effect. On 5/12/26 at 2:30 PM, observation of the survey binder in the lobby showed the most recent survey results available were dated 11/14/25. During an interview on 5/12/26 at 2:40 PM, the ADM confirmed the binder did not include the most recent survey results from December 2025 and stated residents and family members had the right to read the results and ask questions. Review of the facility policy, Resident Rights, dated 10/25, did not include language related to residents’ right to access the most recent survey results.
Expired Enteral Feedings Found in Nutrition Room
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received appropriate treatment and services related to stored enteral feedings, including preventing complications of enteral feeding. During observation and interview in the nutrition room, surveyors found one box of Glucerna 1.2 containing 6 quart containers of enteral feeding that had exceeded its expiration date and remained in storage. The DON stated the Glucerna feedings were expired and that staff in central supply or any nursing staff member should have removed the formula because residents could receive expired feedings and become sick. The DON also stated the facility did not have any residents who received Glucerna 1.2 cal feedings, but acknowledged there was always the possibility nursing staff could grab the wrong feeding and give it to the wrong resident. The DON further stated the facility did not have a policy on expired enteral feedings.
Inadequate Perineal Care During Incontinence Care
Penalty
Summary
The facility failed to ensure appropriate incontinence care for two residents who were incontinent of bowel and bladder or had a urinary catheter. Resident #13, a female with dementia, severe cognitive impairment, protein calorie malnutrition, and osteoporosis, was always incontinent of bladder and bowel according to the MDS and had a care plan directing staff to check for incontinence and wash, rinse, and dry the perineum. During observed care, CNA-B removed the soiled brief and cleaned the groin and vaginal area, but did not separate the labia to thoroughly clean the vaginal area and did not clean the resident’s pubic area before turning her to clean the buttocks. CNA-B later stated she did not open the labia or clean the pubic area and acknowledged those areas should have been cleaned. Resident #126, a male readmitted with diagnoses including hemiplegia and malignant neoplasm of the colon, had a baseline care plan noting a urinary catheter and bowel incontinence with instructions to check for incontinence and wash, rinse, and dry the perineum. During observed care, CNA-C removed the soiled brief and cleaned the groin, penis, and urinary catheter, then turned the resident to clean the buttocks without cleaning the pubic area. CNA-C stated she did not clean the pubic area and said it should have been cleaned. The DON stated both CNAs should have cleaned the residents’ pubic areas, and the facility policy on perineal care required washing the pubic area and, for females, washing thoroughly beginning at the base of the labia.
Failure to Obtain Self-Administration Order for Nasal Medication
Penalty
Summary
The facility failed to ensure a resident’s right to self-administer medication when clinically appropriate for Resident #57, who had diagnoses including sepsis, COPD, hypertension, and malignant neoplasm of the colon. The resident’s admission MDS showed a BIMS score of 15/15, indicating intact cognition, and the resident required varying levels of assistance with some activities of daily living. The resident had an order for Fluticasone Propionate Nasal Suspension, 1 spray in both nostrils daily for allergies, but there was no care plan related to self-administration of this medication and no physician order authorizing self-administration. During observation, MA-D handed the Fluticasone Propionate Nasal Suspension to Resident #57, and the resident sprayed the medication into each nostril by himself before returning it to MA-D. MA-D stated she gave the medication to the resident for self-administration because he wanted to do it himself and had no cognitive impairment, and she said she had notified nurses but received no direction. LVN-E stated the resident was able to self-administer the nasal spray, but there was no physician order for self-administration. The DON stated the interdisciplinary team should have assessed the resident’s ability to self-administer medications and that the resident’s cognitive, communication, visual, and physical abilities should have been evaluated, but the facility had not obtained the required physician order.
Unattended Computer Displayed Resident PHI
Penalty
Summary
The facility failed to keep a resident’s personal and medical records private and confidential when an LVN left her computer open and unattended on a nursing cart in the 300-hallway with Resident #86’s electronic MAR displayed. Resident #86 was a [AGE]-year-old female who was originally admitted and later re-admitted to the facility with diagnoses including type 2 diabetes mellitus, osteoporosis, hypothyroidism, and neuropathy. Her quarterly MDS assessment dated 09/23/2025 showed a BIMS score of 7 out of 15, indicating severe cognitive impairment, and that she had received insulin injections during the last 7 days. During observation, the LVN opened the computer on the cart and viewed Resident #86’s electronic MAR, then removed the resident’s glucometer, lancet, alcohol swap, and gauze from the cart and placed them in a basket. The LVN then knocked on the resident’s door and entered the room without closing or logging off the computer, leaving the screen visible with the resident’s face photo, date of birth, and medications to be provided. The LVN stated she left the computer open with the resident’s personal and medical information on the cart and acknowledged it was a privacy violation because anybody could see the information. The DON stated the nurse should have closed or logged off the computer and identified the event as a HIPAA violation.
MDS Assessments Incorrectly Coded for PASRR Status
Penalty
Summary
The facility failed to ensure Resident #11’s MDS assessments accurately reflected PASRR status. Resident #11’s record showed diagnoses including schizophrenia unspecified, bipolar disorder unspecified, and unspecified intellectual disabilities. The admission 5-day MDS dated 02/07/2025 and the Significant Change MDS dated 09/28/2025 both coded Section A1500 PASRR as 0 (No), indicating the resident was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The resident’s record also included a care plan with a focus of PASRR positive and habilitation coordination, a PASRR Level 1 Screening dated 02/03/2025 that coded yes for mental illness, intellectual disability, and developmental disability, and a PASRR Evaluation dated 03/06/2025 that coded yes for developmental disability other than an intellectual disability that manifested before age 22. During interview, the MDS Nurse stated the resident was PASRR positive and received habilitative services, and stated the MDS assessments should have been coded yes for PASRR. The DON stated the MDS Nurse was responsible for MDS accuracy and that accurate coding was important to trigger needed services.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors determined the medication error rate was 7.41% based on 2 errors out of 27 opportunities, involving two of five residents reviewed for medication errors. The report states that these errors involved Resident #57 and Resident #18 and were identified through observation, interview, and record review. Resident #57 was a male with diagnoses including sepsis, COPD, hypertension, and malignant neoplasm of the colon. His physician order directed Fluticasone Propionate Nasal Suspension, 1 spray in both nostrils one time a day for allergies, and the MAR reflected that same order. During observation, MA-D gave the medication to the resident, and the resident administered two sprays to each nostril by himself. During interview, MA-D stated she gave the medication to the resident and he took two sprays in each nostril, but the order was for one spray to each nostril. The DON stated this was a medication error and that MA-D should have reeducated the resident when giving the medication. Resident #18 was a male with diagnoses including cerebral infarction, chronic respiratory failure, severe protein-calorie malnutrition, and type 2 diabetes mellitus. His physician order directed Enulose solution 10 gm/15 ml, give 30 ml by mouth two times a day for constipation, but the MAR reflected the medication as scheduled for 30 ml twice daily. During observation, MA-D gave the resident 15 ml, and the resident took 15 ml. MA-D later stated she should have administered 30 ml as ordered but was confused about the dosage. The DON stated the resident should have received 30 ml and that receiving 15 ml was a medication error. The facility policy on medication administration required verification of medication cards with medication orders and checking the label against the order.
Insulin Pens Stored Without Open Dates
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles for two residents receiving insulin. During storage observation on 12/02/2025, Resident #130’s insulin Degludec Flex Pen was found inside the 100-wing nursing cart with no open date, and Resident #81’s insulin Glargine-yfgn Flex Pen was also found inside the same cart with no open date. The report states both pens were being stored in the nursing cart at the time of the surveyor observation. Resident #130 was a male admitted with diagnoses including sepsis, COPD, type 2 diabetes mellitus, and hypertension. He had a physician order for Insulin Degludec 10 units subcutaneously at bedtime, and the MAR showed the insulin was being administered at 8:00 p.m. The insulin box indicated that after first use it should be stored at room temperature for up to 56 days. LVN-F stated the pen should have been discarded 56 days after opening, but because there was no open date, staff did not know when it should be discarded and did not know when the facility nurses had opened it. Resident #81 was a male with diagnoses including encephalopathy, type 2 diabetes mellitus, protein-calorie malnutrition, and hypertension. His MDS showed a BIMS score of 4 out of 15, indicating severe cognitive impairment, and he had an order for Insulin Glargine-yfgn 10 units subcutaneously at bedtime. The MAR showed the insulin was being administered at 8:00 p.m. The insulin box indicated discard after 28 days. LVN-F stated the pen should have been discarded 28 days after opening, but because there was no open date, staff did not know when it should be discarded or when it had been opened.
Unsafe Puree Diet Preparation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during puree diet preparation in the kitchen. During observation on 12/03/2025 at 10:46 a.m., a dietary staff member was seen using a processor to prepare pureed pork loin. The processor was placed on one side of the counter near the 2-compartment sink, with a pot of pork loin beside it. The staff member scooped pork loin with a large cooking spoon and placed it in the processor to puree it. After blending the pork loin, the staff member reached across the 2-compartment sink and grabbed a plastic liquid measuring cup that was sitting on the metal counter with liquid droplets around and near it. The measuring cup was placed into the pot of pork loin to gather broth, which was then poured into the processor, and the staff member continued blending. The measuring cup was left in the pot while the pork loin was being pureed and was again pressed down into the pot to gather broth. During interview, the staff member stated this risked cross contamination because the measuring cup had been sitting on the counter and had not been sanitized before use, and because the cup was dipped into the pork loin for broth. The DS stated the staff member should have used a ladle instead of grabbing a cup from the counter and placing it into the pork loin, and the facility policy stated utensils, cups, glasses, and dishes must be handled to avoid touching surfaces with which food or drink will come in contact.
Incomplete Documentation of Oxygen Administration
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for one resident, identified as Resident #16, out of 27 residents reviewed. Resident #16 was a [AGE]-year-old female admitted with diagnoses including type 2 diabetes mellitus, protein-calorie malnutrition, heart failure, and peripheral vascular disease. Her quarterly MDS showed a BIMS score of 7 out of 15, indicating severe cognitive impairment, and she required dependent assistance for transfers and was receiving oxygen therapy. Her care plan included oxygen therapy related to ineffective gas exchange, with an intervention for oxygen per MD orders. The resident had a physician order for oxygen at 2 LPM via nasal cannula continuously as needed for shortness of breath or wheezing. Review of the MAR for 12/01/2025 through 12/31/2025 showed the oxygen order was scheduled as needed, but the entries for 12/01/2025, 12/02/2025, and 12/03/2025 were left blank. During observation, the resident was seen in her room sitting in a wheelchair with oxygen at 2 liters per minute via nasal cannula, and the oxygen tubing and nasal cannula were labeled as changed on 12/01/2025. An LVN stated that nurses administered the oxygen on 12/01/2025, 12/02/2025, and 12/03/2025 but did not document it on the MAR, and the DON stated the nurses should have documented the oxygen administration to keep accurate medical records and communicate with other nurses. The facility policy on Oxygen Administration stated to document all appropriate information in the medical record for oxygen therapy.
Failure to Include Bed Rails in Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, specifically regarding the use of bed rails. Resident #226, a male with severe vision impairment and hemiplegia following a stroke, was admitted without the use of bed rails being included in his care plan. Despite being informed of the potential dangers of bed rails, the resident's care plan did not address their use, and observations confirmed the bed rails were consistently in use without being documented in the care plan. Similarly, Resident #221, a female with muscle wasting and atrophy, was admitted with a baseline care plan that did not include the use of bed rails, despite her cognitive impairments. Observations showed that the bed rails were always up, and the resident used them for repositioning, yet this was not reflected in her care plan. The resident was aware of the bed rails but did not know how to lower them, indicating a lack of comprehensive planning and staff awareness. Resident #320, a male with dementia and Parkinson's disease, also had a care plan that failed to include the use of bed rails. Although there were orders for mobility aids, the care plan did not document the use of bed rails, which were observed in the upright position. The Director of Nursing acknowledged that bed rails were used as enablers and required physician orders, consent, and inclusion in the care plan, which was not done for these residents. This oversight could lead to residents not receiving necessary care or services tailored to their specific needs.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for three residents, leading to a deficiency in their care. For Resident #226, the facility did not attempt to use appropriate alternatives before installing bed rails and failed to assess the resident for the risk of entrapment. Despite the resident's severe vision impairment and paralysis, the necessary documentation indicating attempts to use alternatives was left blank. Observations showed the resident with bed rails up, although he had never used them. Similarly, for Resident #221, the facility did not explore alternatives before installing bed rails and did not assess the risk of entrapment. The resident, who had muscle wasting and cognitive impairments, was observed with bed rails up and was unaware of how to lower them. The Director of Nursing (DON) confirmed that bed rails were used as enablers and required physician orders, consent, and care planning, which were not adequately documented. For Resident #320, the facility also failed to conduct a proper assessment for the use of bed rails. The resident, diagnosed with dementia and Parkinson's disease, had no documented evaluation for the use of bed rails. Observations revealed the resident with bed rails up and side bolsters on the mattress, yet the baseline care plan did not include the use of bed rails. The facility's policy on mobility bars was not followed, as the necessary informed consent and assessment were not completed.
Food Storage and Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. An opened bag of shredded cheddar cheese was found in the reach-in cooler, stored in a clear, gallon-sized storage bag with a zipper-seal that was left open. This oversight was acknowledged by the dietary staff (DS), who confirmed that all food should be properly labeled, dated, and stored in sealed containers to prevent cross-contamination and spoilage. Additionally, a storage bag containing cooked pork was found unsealed and without a use-by date, contrary to the facility's policy of using leftovers within seven days. The DS confirmed that all dietary staff were trained to store leftover food in sealed bags or containers with appropriate labeling and dating. Furthermore, a mop was improperly stored in the equipment storage closet with the mop head on the ground, preventing it from air drying. The DS acknowledged that the mop should have been stored on a hook to allow for proper drying. The facility's dietary policies, based on the Texas Food Establishment Rules (TFER) and the U.S. Public Health Service Food Code, were not followed in these instances, which could potentially place residents at risk for foodborne illness.
Failure to Properly Document Resident's DNR Order
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order was properly included and completed in the medical record. The resident, a male with dementia, Parkinson's disease, and adult failure to thrive, was admitted to the facility with a DNR status. However, the DNR document in the resident's file was incomplete, lacking the necessary witness or responsible party (RP) signature at the bottom, despite having two physician signatures. Interviews revealed that the social worker (SW) was unaware of any pending DNRs and was uncertain about the resident's DNR status or its location, as they had just started at the facility. The Director of Nursing (DON) acknowledged that the clinical staff was assisting the new SW with DNR paperwork and admitted that if the resident had coded, CPR would have been performed due to the delay in locating the DNR. The DON also incorrectly stated that the RP's signature was unnecessary because of the two provider signatures. Further investigation showed that the resident's RP did not complete a DNR form and expressed concern about a forged signature on the document. The RP confirmed a desire for a DNR but stated that the facility did not request any paperwork, and discussions about the DNR only occurred with hospital staff before the resident's admission. The facility's policy on advance directives was not followed, as it required providing written information about advance directives and documenting the resident's or RP's wishes in the health record.
Inadequate Catheter Care Leads to Deficiencies
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to potential risks of urinary tract infections. Resident #77, a male with severe cognitive impairment and an indwelling urinary catheter, was observed with a catheter bag filled with approximately 1,200 ml of urine. During catheter care, the CNA placed the catheter bag on the bed, which could lead to backflow and potential infection. The CNA acknowledged the oversight and the Director of Nursing confirmed the risk of infection due to improper handling of the catheter bag. Resident #312, a male with an indwelling urinary catheter, was observed receiving inadequate catheter and perineal care. The CNA cleaned the resident's penis in the wrong direction, failed to clean the scrotum and under it, and did not fully separate the buttocks to clean between the folds. The resident had purulent discharge from the urethra, and the CNA admitted to not being familiar with the resident's care needs. The DON confirmed that improper cleaning could lead to infection, and the resident had been diagnosed with a UTI and required IV antibiotics. Both CNAs involved had completed training and competency reviews for catheter care, yet failed to adhere to proper procedures. The facility's policy required catheter care to promote hygiene and reduce infection risk, but these standards were not met in the observed cases, leading to deficiencies in care for the residents.
Failure in Dialysis Communication and Coordination
Penalty
Summary
The facility failed to ensure proper communication, coordination, and collaboration with the dialysis facility for two residents requiring dialysis services. For Resident #226, the facility did not maintain complete and accurate documentation on the Renal Dialysis Communication Forms. Specifically, the form dated 9/23/24 was missing the dialysis staff's signature, and the form dated 9/26/24 contained a request for information regarding the resident's elevated blood pressure, which was not confirmed as received by the dialysis clinic. Interviews with the ADON and DON revealed that the forms were not checked for completeness in a timely manner, and there was uncertainty about whether the necessary information had been communicated to the dialysis clinic. For Resident #75, the facility also failed to complete the Renal Dialysis Communication Forms accurately. The form for 9/17/24 was missing entirely, and the forms for 9/24/24 and 9/26/24 were not completed upon the resident's return from dialysis. Additionally, it was noted that the resident missed dialysis on 9/17/24, which was documented by LVN E. The ADON acknowledged the oversight in reviewing the forms and confirmed that the resident did not attend dialysis on the specified date. The facility's policy and procedure for dialysis care, dated 3/2009, emphasized the importance of ongoing communication and collaboration with the dialysis facility. However, the facility did not adhere to these standards, resulting in incomplete documentation and potential lapses in communication regarding the residents' dialysis care. This deficiency could affect the residents receiving dialysis treatments, placing them at risk for complications and inadequate care.
Failure to Coordinate Hospice Care and Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services, specifically for one resident reviewed. This deficiency was identified through interviews and record reviews, which revealed that the facility did not ensure the availability of the most recent plan of care, DNR, and hospice physician orders for a resident. The absence of these critical documents in the resident's hospice binder and electronic medical record indicated a lack of proper documentation, coordination of care, and communication of resident needs. The report highlights that the facility's Director of Nursing (DON) and Social Worker (SW) were unaware of the location of the DNR and other hospice-related documents, which could have led to inadequate end-of-life care. The DON admitted that if an emergency had occurred, the resident might have received CPR due to the delay in locating the DNR. The facility's policy on end-of-life care emphasizes the importance of individualized care plans and collaboration with hospice services, which was not adhered to in this case.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents with indwelling urinary catheters. In the first incident, a CNA did not perform appropriate hand hygiene after removing gloves during catheter care for a resident. This resident, who was severely cognitively impaired and had a history of urinary tract issues, was at risk of infection due to the CNA's failure to sanitize or wash hands after glove removal, which was acknowledged by both the CNA and the Director of Nursing (DON) as a breach of proper infection control practices. In the second incident, another resident's catheter tubing was observed touching the floor, and staff failed to use enhanced barrier precautions (EBP) when providing care. This resident, who had recently been admitted and had undergone surgical amputation, was on EBP due to the presence of an indwelling urinary catheter. Despite this, staff did not wear gowns while repositioning the resident, which involved high-contact activities that required such precautions according to the facility's policy. The DON confirmed that the catheter tubing should not touch the floor and that staff should wear gowns during high-contact care activities. Both incidents highlight lapses in adherence to infection control protocols, specifically regarding hand hygiene and the use of personal protective equipment (PPE) during care of residents with indwelling medical devices. These deficiencies were identified through observations, interviews, and record reviews, and were acknowledged by the facility's DON as practices that could increase the risk of infection among residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 890 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mccullough Hall Nursing Center Inc | 0.8 mi | — | 0 | 0 |
| Avir At San Antonio | 0.8 mi | ★★★★★ | 34 | 1 |
| Hunters Pond Rehabilitation And Healthcare | 1.8 mi | ★★★★★ | 10 | 0 |
| San Jose Nursing Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Windsor Mission Oaks | 3.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Legend Oaks Healthcare And Rehabilitation Center -.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.