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-kyle during CMS and state inspections, most recent first.
A facility failed to ensure that oxygen tubing and humidifier bottles were changed as ordered for three residents receiving continuous O2 therapy. The residents had diagnoses including COPD, pneumonia, and acute/chronic respiratory failure, and observation showed the humidifier bottles were still dated from the prior week. An LPN stated he was responsible for the Sunday night task but forgot to complete it and documented it as done before actually performing it; the DON stated the equipment should be replaced as ordered and documented only after completion.
False Documentation of Oxygen Equipment Changes: An LPN documented oxygen tubing and humidifier bottle changes for three residents on the MAR before actually completing the task. The residents were on continuous O2 therapy and had physician orders for weekly Sunday night-shift changes. During observation, the equipment showed earlier change dates than what was charted, and another nurse later confirmed the items had not been changed as documented.
Surveyors found that multiple residents had stained privacy curtains that were not promptly cleaned or replaced, despite repeated work orders documenting large dark or feces-like stains and bowel movement on the curtains. One resident with post-stroke hemiplegia and moderate cognitive impairment reported that a CNA splattered bowel movement on his curtain, attempted to wipe it off, and that the stain remained for weeks, affecting family visits. Other residents with conditions including paroxysmal AFib, muscle weakness, post-polio syndrome, and major depressive disorder reported brown splatters and streaks on their curtains and believed they were rarely laundered. Staff interviews showed reliance on a TELS work-order system, uncertainty among nursing staff about laundering frequency, and a practice of monthly deep-cleaning rotations, resulting in stained curtains remaining in resident rooms for extended periods.
A resident with a history of stroke and moderate cognitive impairment, but described by staff as able to consent and oriented, was started on oseltamivir (Tamiflu) prophylaxis after exposure to influenza A. The resident’s POA documents granted only financial authority to family members, with no medical decision-making authority, yet staff documented notifying the responsible party and obtaining approval for the medication without documenting any discussion with the resident. The resident reported he was not told about the new flu medication or its purpose until several days later, learning of it from family rather than staff, and stated he was capable of making his own decisions and wanted to be consulted. Multiple staff, including an LPN, RN, ADON, DONs, and the administrator, acknowledged that residents should be informed of new medications and that this should be documented, but there was no record that this resident was informed prior to initiation of the antiviral therapy.
Delayed Wound Care for a Coccyx Pressure Ulcer: A resident with ESRD, DM II, and CHF was admitted with a stage 3 coccyx pressure ulcer, but wound care was not initiated until several days later. The chart contained conflicting admission skin documentation, shower sheets did not note the wound, and the WCN said she was not notified until later and started treatment only after assessing the wound. Interviews with the resident, MD, NP, DON, and WCN showed the facility expected admission skin assessment, provider notification, and wound orders to occur when the wound was identified, but that did not happen promptly.
The facility failed to keep kitchen equipment clean and to ensure the dishwasher sanitized properly. A dirty deep fryer was observed with crumbs, residue, and debris in the oil and basket, and the DS stated the fryer was supposed to be deep cleaned weekly and cleaned after each use. The commercial dishwasher also tested below the expected chlorine PPM during observation, and the DS and DA both noted the sanitizer level was not adequate until the equipment issue was later identified.
Admission MDS Omitted Present-on-Admission Pressure Wound A resident with ESRD, DM II, and CHF was admitted with a stage 3 coccyx pressure ulcer that was not included on the admission MDS, even though later records identified the wound as present on admission. The chart contained conflicting admission skin assessments, nursing notes documenting the sacral wound and other skin findings, and later wound assessments showing the coccyx ulcer as chronic and then deteriorating. Staff interviews showed the MDS Coordinator relied on the clinical admission assessment, while the DON identified a discrepancy in the initial skin documentation.
Failure to use EBP PPE during perineal care. Staff were observed providing perineal care to two residents with wound/indwelling-device precautions without putting on the gown PPE kept outside the rooms. One resident's family member reported staff used gloves but not the blue gowns, and multiple staff members stated they understood EBP required gowns and gloves for high-contact care such as hygiene and toileting.
A medical assistant in an LTC facility failed to sanitize a blood pressure monitor between uses on two residents, both with severe cognitive impairments and multiple health conditions. Additionally, personal drinks were observed on the medication cart, contrary to facility policy. The facility's infection control program requires equipment disinfection to prevent infection spread.
A resident with severe cognitive impairment was physically and emotionally abused by another resident with moderate cognitive impairment and behavioral issues. The incident occurred when the aggressive resident grabbed the other's arm, causing redness, as she attempted to enter a room. Despite staff training on abuse and neglect, the facility failed to prevent this altercation.
Two residents in an LTC facility were observed wearing dirty clothing throughout the day, compromising their dignity. Despite requiring assistance with personal care, staff failed to change their soiled clothes after meals, as per facility policy. Interviews with staff revealed a lack of adherence to the expected practice of maintaining residents' dignity by ensuring clean clothing.
The facility failed to ensure resident privacy by not knocking before entering rooms. Staff members entered the rooms of four residents without knocking, violating their right to privacy. Despite being aware of the policy, staff cited reasons such as rushing or habit for not adhering to it. Residents expressed mixed feelings, with some desiring consistent knocking. The facility's policy emphasizes residents' rights to dignity and privacy.
The facility failed to maintain professional standards for food service safety due to inadequate hand hygiene by Cook C during food preparation. Despite training, Cook C did not wash hands between tasks, potentially risking cross-contamination. Interviews confirmed staff awareness of hand hygiene protocols, but these were not followed, as observed during the preparation of pureed foods.
A resident's OOH-DNR form was found incomplete, missing required signatures from the resident, witnesses, and physician, leading to a deficiency in honoring the resident's rights to request, refuse, and/or discontinue treatment. Despite the resident's care plan indicating a DNR status, the form's invalidity was confirmed by staff, highlighting a failure in the facility's process for verifying advanced directives.
A resident with dementia and other health issues did not receive necessary nail care, resulting in long, jagged, and dirty fingernails. Despite requiring moderate to extensive assistance with personal hygiene, there was no documentation of nail care for nearly a month. Interviews with staff revealed a lack of clarity and responsibility regarding nail care, placing the resident at risk of skin tears and infection.
The facility failed to assist two residents in obtaining necessary dental services, despite their requests and visible dental issues. Both residents, who were cognitively intact, had not seen a dentist in the past year. Staff interviews revealed a lack of communication and follow-up regarding their dental needs, and the facility did not adhere to its policy requiring prompt referral for dental services.
A resident's call light system was found to be non-functional, preventing them from alerting staff for assistance. The resident, who was at risk for falls, expressed concerns about staff response times. Staff confirmed the malfunction, and faulty wiring was identified and replaced. The facility's policy required immediate reporting of defective call lights.
Failure to Change Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to ensure that residents who were receiving oxygen therapy had their humidifier water bottles and oxygen tubing changed as ordered. Three residents were reviewed for respiratory care: one resident with multiple rib fractures, acute and chronic respiratory failure with hypoxia, and COPD; a second resident with pneumonia and a personal history of respiratory disease; and a third resident with acute respiratory failure with hypoxia and pneumonia. Each resident had a physician’s order directing that the oxygen tubing and humidifier bottle be changed every Sunday on the night shift, and each was observed on the unit receiving continuous oxygen therapy through an oxygen concentrator. During observation, the humidifier bottles for all three residents were dated several days earlier than expected, showing that the equipment had not been changed on the ordered Sunday. Record review of the MAR showed that an LPN documented the oxygen tubing and humidifier bottle as changed on the Sunday night shift, but the equipment remained unchanged when observed later. In interview, the LPN stated that he was responsible for completing the task on the Sunday night shift, that he had intended to do it but forgot because he was occupied with other nursing tasks, and that he documented the task as completed before actually performing it. He stated that this was not compliant with professional standards. A charge nurse later stated that she replaced the humidifier bottles and oxygen tubing for all three residents because they had not been changed as ordered. The DON stated that humidifier bottles, tubing, and oxygen nasal cannulas should be removed and replaced as ordered to minimize the risk of respiratory infections caused by contaminated equipment, and that nurses should document tasks only after they have been completed. The record also showed no in-services since March 2026 on safe handling of respiratory equipment, and the facility policy required oxygen tubing, masks or nasal prongs, and disposable humidifiers to be replaced every seven days.
False Documentation of Oxygen Equipment Changes
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for three residents receiving oxygen therapy. Resident #1, Resident #2, and Resident #3 each had physician orders requiring the oxygen tubing and humidifier bottle to be changed every Sunday night shift, and each resident was observed on continuous oxygen therapy in Hall 100 during the survey. For Resident #1, the humidifier bottle showed a changed date of 05/18/26 during observation, while the MAR documented the tubing and humidifier bottle as changed on 05/24/26. For Resident #2, the humidifier bottle also showed a changed date of 05/18/26, but the MAR documented the change on 05/24/26. For Resident #3, the humidifier bottle showed a changed date of 05/17/26, while the MAR documented the change on 05/24/26. Resident #1 was an elderly female with diagnoses including multiple rib fractures, acute and chronic respiratory failure with hypoxia, COPD, type 2 diabetes, muscle weakness, and unsteadiness on feet. Her MDS reflected a BIMS score of 12 and that she was on oxygen therapy. Resident #2 was an elderly female with pneumonia, heart failure, chronic kidney disease, dementia, muscle weakness, hypertension, and need for assistance with personal care; her MDS reflected a BIMS score of 7 and oxygen therapy use. Resident #3 was an elderly female with acute respiratory failure with hypoxia, pneumonia, muscle weakness, unsteadiness on feet, and lack of coordination; her MDS reflected a BIMS score of 15 and did not reflect her diagnosis of acute respiratory failure. During interview, LPN A stated he was the Sunday night shift nurse responsible for changing the humidifier bottles and oxygen tubes for residents on Hall 100. He said he intended to do the task but forgot because he was occupied with other nursing duties, and he acknowledged that he documented the task as completed in the MAR before actually performing it. LVN B later confirmed that the humidifier bottles and oxygen tubes for all three residents had not been changed on the specified date and that she replaced them after being asked to check. The DON stated that humidifier bottles, tubing, and oxygen nasal cannulas should be removed and replaced as ordered, and that nurses are supposed to document only after the task has been completed.
Soiled Privacy Curtains Not Timely Cleaned or Replaced
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not ensuring that privacy curtains for three residents were free of stains. For Resident #1, a male with a history of cerebral infarction and resulting hemiplegia/hemiparesis and moderate cognitive impairment (BIMS 12), surveyors observed housekeeping staff on a ladder replacing the middle privacy curtain in his room. Resident #1 reported that the curtain had been dirty for approximately two to three weeks, stating that a CNA had splattered bowel movement on the curtain while changing his roommate, attempted to wipe it off, but the stain remained and no one made an effort to clean it afterward. He also reported that a similar incident had occurred previously, that his family member had reported it, and that his family did not want to sit near the curtain during visits. For Resident #2, a female with paroxysmal atrial fibrillation, muscle weakness, and a cognitive communication deficit but no cognitive impairment (BIMS 14), observation revealed several brown splattered dots on the privacy curtain between her and her roommate. Resident #2 stated she did not know what was on the curtain, wished it could be washed, and was unsure if the curtain had ever been washed since she had been in the room. For Resident #3, a male with post-polio syndrome, major depressive disorder, and a need for assistance with personal care, and no cognitive impairment (BIMS 15), observation showed brown streaks and spots on the middle privacy curtain in his room. Resident #3 stated he did not think the curtain was laundered very often and believed the stains were food. Staff interviews revealed inconsistent understanding and implementation of procedures for handling soiled privacy curtains. CNAs and nursing staff reported that when curtains were soiled, they were to submit a work order in the TELS system and notify maintenance or housekeeping, and that nursing staff could not remove curtains themselves. Some staff, including an LVN and an RN, were unsure about the routine frequency for laundering curtains. The housekeeping supervisor and maintenance staff stated that privacy curtains were laundered on a monthly deep-cleaning rotation and as needed via TELS work orders, with increased urgency if bodily fluids or bowel movement were noted. Review of TELS work order logs showed multiple requests over several weeks for curtains in Resident #1’s room and another room to be changed or washed due to large dark or feces-like stains, including repeated notes that the curtain had a large stain that looked like feces for well over two weeks, and specific entries indicating the curtain had bowel movement or “poop” on it. The facility’s physical environment policy stated that TELS was used to track and document maintenance and regular tasks to keep the facility in good working order for resident and staff safety.
Failure to Inform Cognitively Capable Resident of New Antiviral Prophylaxis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively capable resident was informed of and allowed to participate in decisions regarding a new medication order. The resident was an older male with a history of cerebral infarction and resulting hemiplegia/hemiparesis, with a quarterly MDS BIMS score of 12 indicating moderate cognitive impairment. His face sheet and POA documents identified two family members as financial POA only, with no medical decision-making authority or MPOA designation. The resident’s care plan noted risk for impaired cognitive function, but staff interviews consistently described him as able to consent to his own treatment, oriented, and able to recognize people and express his needs. Record review showed that on a January date, the resident was exposed to influenza A in the facility and, per protocol, was started on oseltamivir (Tamiflu) 75 mg orally once daily for influenza A prophylaxis for 14 days, ordered by the in-house provider. A nursing progress note documented that the responsible party was notified and approved the medication, but there was no documentation from the NP, ADON, LVN, or any other staff that the resident himself was informed of the new medication or its purpose between the start of therapy and the survey date. The resident’s immunization record showed he had already received an influenza vaccine earlier in the season, and there was no indication in the chart that he had been found incompetent by a court of law, as referenced in the facility’s resident rights policy. During interviews, the resident stated he was started on “flu medication” and did not learn what it was for until about three days later, after a family member asked if he knew he had been started on Tamiflu and told him the facility had contacted another family member for permission. He stated that he was not “crazy,” could still make his own decisions, and wanted the facility to contact family only if he was unable to decide for himself. He reported that no one came to ask him about starting the medication or whether he wanted to take it. Multiple staff members, including an LVN, RN, ADON, DONs, and the administrator, described that residents should be notified of new medications and that this should be documented, and several acknowledged that this was important for resident autonomy and involvement in care. However, the LVN could not recall if this resident was notified, the ADON stated the nurse or NP was responsible for speaking with residents, and the DON later asserted that the NP had notified this resident, despite the absence of documentation and the resident’s statement that he had not been informed in advance.
Delayed Wound Care for a Coccyx Pressure Ulcer
Penalty
Summary
The facility failed to ensure Resident #90 received necessary wound care treatment for a stage 3 coccyx pressure ulcer for eight days after admission, from 11/26/2025 to 12/04/2025. Resident #90 was admitted with diagnoses including end stage renal disease, diabetes mellitus II, and congestive heart failure. The admission MDS dated 11/29/2025 indicated a BIMS score of 15 and reflected the resident was at risk for pressure ulcers but had no unhealed pressure ulcers at that time. However, the clinical admission assessment dated 11/26/2025 documented a pressure ulcer at the sacrum, while the 11/28/2025 assessment documented no skin issues. The record showed conflicting documentation about the wound on admission and no wound care orders were implemented until 12/04/2025. The wound care nurse stated she was not notified about the wound until 12/03/2025 and that treatment started on 12/04/2025. She also stated the resident had a lot of serosanguineous drainage on admission and that the wound had more slough when she assessed it on 12/03/2025 than when she first saw it. The resident’s shower sheets from 11/26/2025 to 12/04/2025 did not document any skin issues, despite the resident receiving showers on several of those dates. During interviews, the resident stated she had a wound to her sacrum before admission and did not feel it was cared for appropriately. The MD and NP stated they expected nursing to identify wounds on admission and initiate wound care orders, and the DON stated that if a wound was present on admission, the admitting nurse should have completed a full skin assessment, notified the provider, initiated orders, and notified the WCN. Facility policy required a licensed nurse to assess skin on admission, document all areas of breakdown, and administer treatment once an area of altered skin integrity had been identified and documented. On 12/11/2025, the wound was observed as malodorous with measurements of 4.2 cm x 6.5 cm x 3 cm and 70% light green slough, with the old dressing saturated in brown drainage.
Dirty fryer and inadequate dishwasher sanitizing
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety in the kitchen. During observation on 12/09/2025 at 9:03 a.m., the deep fryer was covered in cornmeal breading crumbs, with crumbs on the rim and floating in the oil, dark brown streaks on the inside walls, and crumbs and other solid matter embedded in the fry basket wires. During interview, the DS stated the fryer was deep cleaned weekly and food particles were cleaned daily after each meal, and he said the fryer had last been used the day before for fish cakes. Later that morning, the DM, a dietary manager from a sister facility, was observed cleaning and scrubbing the deep fryer. After he finished, the crumbs and brown streaks were no longer present. Review of an undated kitchen document titled Friday Weekly Deep Cleaning Day showed the DS was responsible for cleaning the fryer machine, and the DS later stated he did not think he had completed the deep clean on 12/05/2025. The commercial dishwasher also did not meet the minimum required threshold for chemical sanitizing during observation on 12/09/2025 at 9:10 a.m. The DA tested the dishwasher and the chlorine test strip measured 25 PPM, which he believed should have been 50 PPM. He stated he had adjusted the chemical flow but did not explain what he had done, and the DS also tested the machine and obtained the same result. The DS stated the dishwasher technician later found that one of the hoses delivering chlorine sanitizer had disconnected and fixed the problem. A December 2025 dishwasher log showed sanitizer PPM marked at 50 for every meal entry, with wash and rinse temperatures at 120 degrees Fahrenheit.
Admission MDS Omitted Present-on-Admission Pressure Wound
Penalty
Summary
The facility failed to conduct an accurate admission assessment for one resident by not including a pressure wound that was present on admission in the admission MDS assessment. The resident was admitted with diagnoses including end stage renal disease, diabetes mellitus II, and congestive heart failure. The admission MDS dated 11/29/2025 indicated the resident had no unhealed pressure ulcers, even though the record later reflected a stage 3 coccyx pressure ulcer that was present on admission. Record review showed conflicting admission skin documentation. One clinical admission assessment dated 11/26/2025 noted a pressure ulcer at the sacrum, while another clinical admission assessment dated 11/28/2025 documented no skin issues. Nursing notes also documented pressure ulcer to the sacrum, discoloration to the left arm fistula area, and surgical wounds on the right leg. A later skin issues assessment dated 12/03/2025 identified a stage 3 pressure ulcer/injury to the coccyx, described as present on admission and chronic for more than 3 months, with measurements of 4.5 by 2.5 by 2 and 80% granulation tissue and 20% slough. A subsequent skin issues assessment dated 12/10/2025 described the coccyx wound as deteriorating, with increased exudate and increased smell, 30% granulation tissue, 70% slough, and heavy seropurulent drainage. During interview, the resident stated the coccyx wound had been present for over a year, had healed at one point, and had reopened about a week before admission. Staff interviews reflected that the MDS Coordinator relied on the clinical admission assessment to complete the skin section of the MDS, that the ADONs trained nurses on the admission process, and that the DON believed the initial clinical admission assessment contained a discrepancy. The facility policy required a licensed nurse to assess skin on admission and document all areas of breakdown, excoriation, discoloration, or other unusual findings.
Failure to Use EBP PPE During Perineal Care
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 of 10 residents reviewed for infection control. The deficiency involved Resident 5, a male admitted with diagnoses including BPH, anemia, glaucoma, recurrent falls, and persistent pain in both hips, and Resident 2, a female with cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and vascular dementia. Both residents had physician orders requiring PPE for high resident contact care activities related to wounds, indwelling medical devices, infection, and/or MDRO status. On 12/10/2025 at 8:39 a.m., LVN J and C.N.A. D were observed providing perineal care to Resident 5 without putting on the gown PPE provided outside the room before starting care. It was also observed that when LVN J exited Resident 5's room with waste, a blue gown could not be seen in the clear waste bag carried to the trash can. Later that morning at 10:22 a.m., LVN J and C.N.A. D were again observed not putting on the PPE gown provided outside Resident 2's room before entering to provide care. Interviews showed that Resident 5's daughter stated staff performed perineal care without the blue gowns kept at the resident's door for enhanced barrier precautions and only wore gloves. Staff interviews reflected that LVN J, C.N.A. D, C.N.A. F, C.N.A. C, LVN H, and ADON B understood enhanced barrier precautions required gowns and gloves for high-contact care such as perineal care, and that failure to follow the precautions placed residents and staff at risk. The facility's IPCP policy stated that enhanced barrier precautions require gown and glove use during high-contact resident care activities, including providing hygiene and changing briefs or assisting with toileting, for residents with wounds and/or indwelling medical devices.
Infection Control Breach with Blood Pressure Monitor
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medical assistant (MA A) who did not clean and disinfect a blood pressure monitor between uses on two residents. On the specified date, MA A used the same blood pressure monitor on two residents without sanitizing it before, between, or after the measurements. This oversight occurred despite the facility's policy requiring the cleaning and disinfection of equipment to prevent the spread of infections. Additionally, MA A was observed with personal drinks on the medication cart, which is against the facility's policy. The residents involved were both elderly males with multiple diagnoses, including Type 2 diabetes, hypertension, and dementia, and both had severely impaired cognition as indicated by their BIMS scores. The facility's policy on infection prevention and control, revised in December 2023, outlines the importance of cleaning and disinfection procedures for environmental surfaces and equipment. Despite receiving in-service training on infection control, MA A admitted to not following the policy and was unaware of the reasons behind the prohibition of personal food and drinks on the medication cart.
Resident Abuse Incident Due to Inadequate Protection
Penalty
Summary
The facility failed to protect a resident from physical and emotional abuse by another resident. On the date of the incident, Resident #2 screamed at and grabbed the right arm of Resident #1, who had a history of a nondisplaced fracture of the triquetrum bone in the wrist. This altercation resulted in erythema on Resident #1's arm that lasted for four days. The incident was confirmed through a facility investigation and video footage, which showed Resident #2 coming out of her room and grabbing Resident #1's arm as she attempted to enter the room. Resident #1, a female with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and a history of fractures, was known to ambulate via wheelchair and enjoyed looking out the windows in Hall 100. Despite her cognitive deficits, she was described as pleasant and had no behavioral concerns. Resident #2, who had moderate cognitive impairment and a history of behavioral issues, expressed paranoia about intruders due to past trauma and was on antidepressant medication. The facility had attempted to refer Resident #2 to behavioral health services, but the referral was declined by her and her family. The incident was witnessed by staff, including an LVN and MD, who observed Resident #2's aggressive behavior towards Resident #1. The facility's investigation revealed that contrary to initial impressions, Resident #1 had not entered Resident #2's room but was attempting to open the door when the altercation occurred. The facility had conducted in-services on abuse and neglect, as well as on responding to resident altercations, but the measures in place were insufficient to prevent the incident from occurring.
Failure to Maintain Resident Dignity Through Clean Clothing
Penalty
Summary
The facility failed to ensure the dignity of two residents by not maintaining their clothing in a clean state throughout the day. Resident #34, a female with dementia and other conditions requiring extensive assistance with personal care, was observed wearing a dirty t-shirt with yellow stains throughout the day on 09/04/24. Despite being dependent on staff for dressing and personal hygiene, her clothing was not changed after it became soiled, as documented in the care plan and observed by surveyors. Similarly, Resident #67, a male with Parkinson's disease and dementia, was observed on multiple occasions wearing a dirty shirt and clothing protector with food and moisture stains on 09/03/24 and 09/04/24. His family had previously reported the issue to the facility, but it persisted. The resident required substantial assistance with dressing, yet staff failed to change his clothing after meals, as expected by the facility's policy and care plan. Interviews with staff, including CNAs and nursing management, revealed a lack of adherence to the facility's policy of changing residents' clothing after meals if they became dirty. Staff members acknowledged the expectation to change soiled clothing but failed to notice or act upon the residents' needs. The facility's policy on resident rights emphasizes the importance of maintaining dignity, which was compromised by the failure to provide clean clothing, potentially leading to embarrassment for the residents.
Failure to Ensure Resident Privacy by Not Knocking Before Entering Rooms
Penalty
Summary
The facility failed to ensure resident rights for personal privacy for four residents reviewed for personal privacy. Staff members did not knock on the doors of these residents before entering their rooms, which is a violation of the residents' right to privacy. This practice was observed during meal tray passes, where staff entered the rooms of the residents without knocking, potentially causing the residents to feel that their privacy was being invaded. The residents involved in this deficiency included individuals with various medical conditions such as diabetes, heart failure, dementia, and mobility issues. Despite their medical conditions, these residents had varying levels of cognitive ability, with some being able to understand and communicate effectively. Interviews with the residents revealed mixed feelings about the lack of knocking, with some expressing a desire for staff to knock consistently before entering their rooms. Interviews with staff members, including a CNA, an LVN, the DON, and the ADM, revealed that they were aware of the policy requiring staff to knock before entering residents' rooms. However, reasons for not adhering to this policy included being in a rush, habit, or distraction. The facility's policy on resident rights, dated October 4, 2016, clearly states that residents have the right to be treated with dignity and respect, including the right to personal privacy.
Failure in Hand Hygiene During Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the area of hand hygiene, during food preparation in the kitchen. Cook C was observed on multiple occasions not washing her hands between tasks while preparing pureed foods. This included touching various surfaces and equipment, such as the puree machine blade, stove, and steam table, without performing hand hygiene in between these actions. The lack of proper hand hygiene was noted during the preparation of both meat and green peas, which were then served to residents. Interviews with the Dietary Manager (DM), Cook D, and the Administrator (ADM) confirmed that all kitchen staff had been trained on hand hygiene practices, which require washing hands between tasks to prevent cross-contamination and the spread of infections. Despite this training, Cook C did not follow the hand hygiene protocol, potentially placing residents at risk of food-borne illness. The facility's hand hygiene policy, dated October 2022, mandates that all personnel follow handwashing procedures to prevent the spread of infections, yet this was not adhered to during the observed food preparation process.
Incomplete DNR Form Leads to Deficiency in Resident Rights
Penalty
Summary
The facility failed to ensure the proper completion of an out-of-hospital do-not-resuscitate (OOH-DNR) form for a resident, identified as Resident #49, which is a violation of the resident's rights to request, refuse, and/or discontinue treatment. The OOH-DNR form for Resident #49 was missing required signatures from the resident or proxy, witnesses, and the physician, rendering it invalid. This oversight was discovered during a review of the resident's clinical records and interviews with facility staff. Resident #49 was admitted with multiple diagnoses, including an unspecified fracture of the right femur, sequelae of cerebral infarction, unspecified atrial fibrillation, and dysphagia. The resident's care plan indicated a DNR code status, and physician orders confirmed a DNR order. However, the OOH-DNR form dated 06/06/2019 lacked the necessary signatures, which was confirmed by multiple staff members during interviews. The staff, including LVNs, social workers, and the administrator, acknowledged the form's invalidity due to missing signatures and recognized the potential risk of not honoring the resident's wishes. Interviews with staff revealed that the facility's process for verifying advanced directives was not followed. The LVNs and social workers stated that they are responsible for ensuring that DNR forms are complete and valid before being entered into the resident's record. Despite this, the form for Resident #49 was not properly reviewed, leading to the deficiency. The facility's policy requires that advanced directives be reviewed to ensure they reflect the resident's choices and are signed and dated by the appropriate parties, which was not adhered to in this case.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living, received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not ensure that the resident's fingernails were clean and smooth over a period of several days. The resident, an elderly female with a history of dementia, lack of coordination, and other health issues, required moderate to extensive assistance with personal hygiene. Despite this need, there was no documentation of nail care being provided to her for nearly a month. Interviews with facility staff revealed a lack of clarity and responsibility regarding nail care. A CNA mentioned that the resident's nails often got dirty due to her behavior, but there was no specific assignment for nail care. An LVN and the ADON both acknowledged that nail care should be part of regular hygiene routines, but there was no consistent monitoring or reporting of issues. The DON and ADM also confirmed that nail care was expected to be monitored by nursing staff, yet there was no evidence of this being effectively carried out. This oversight placed the resident at risk of skin tears and infection due to long, jagged, and dirty fingernails.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to assist two residents, Resident #46 and Resident #74, in obtaining necessary dental services. Resident #46, who was cognitively intact with a BIMS score of 13, had been experiencing discomfort with her dentures, which was noted in her care plan. Despite her requests to see a dentist and visible buildup on her teeth, there was no record of her having seen a dentist in the past year. Interviews with staff revealed a lack of communication and follow-up regarding her dental needs, with the social worker and administration unsure of why she had not been referred to a dentist. Resident #74, also cognitively intact with a BIMS score of 15, had no teeth or dentures in her mouth during observation. She reported that her dentures had been broken by a CNA months ago, yet there was no documentation of her being offered dental services. Staff interviews indicated that she often requested softer foods and preferred not to wear her dentures, but there was no record of her being referred to a dentist. The facility's policy requires prompt referral for dental services, but this was not adhered to in her case. The facility's policy on dental services states that residents should have access to routine and emergency dental care without barriers, and that the facility should investigate and determine financial responsibility for denture repairs. However, both residents had not been seen by a dentist in the past year, and there was no documentation of efforts to address their dental concerns. The facility's failure to follow its own policy and ensure timely dental care for these residents constitutes a deficiency in care.
Deficiency in Resident Call Light Functionality
Penalty
Summary
The facility failed to ensure that a working call system was available in each resident's bathroom and bathing area, specifically for one resident. The call button in the bedroom of a resident was not functioning properly, as observed during an inspection. The resident, who was at risk for falls and dependent on staff for assistance, was unable to alert staff for help when needed. The resident expressed concerns about the timeliness of staff response when the call light was pressed. Interviews with staff confirmed the malfunction of the call light system. A CNA verified that the call light was not working at the time of observation, although it had been functioning earlier. The maintenance director identified faulty wiring as the cause and replaced it upon discovery. The DON and the Administrator both acknowledged the importance of having a functioning call light system to meet residents' needs promptly. Maintenance logs showed previous tests indicating the call light was functioning, and the facility's policy required immediate reporting of defective call lights.
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 276 citations issued within 25 miles in the last 12 months — including the 18 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kyle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marbridge Villa | 8.3 mi | ★★★★★ | 0 | 0 |
| Brodie Ranch Nursing And Rehabilitation Center | 9.3 mi | ★★★★★ | 3 | 1 |
| Onion Creek Nursing And Rehabilitation Center | 9.7 mi | ★★★★★ | 2 | 0 |
| San Marcos Rehabilitation And Healthcare Center | 10.1 mi | ★★★★★ | 3 | 0 |
| Southpark Meadows Nursing And Rehabilitation Cente | 11.2 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.