Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 - New Br during CMS and state inspections, most recent first.
Oxygen therapy was not consistently provided or maintained as ordered for multiple residents. One resident with COPD, respiratory failure, and bronchitis had an O2 concentrator set at 4.5 L/min instead of the ordered 5 L/min, and an LPN said she had not checked the setting that shift. Two other residents with COPD and other diagnoses were observed using nasal cannulas with dirty concentrator filters, and RN E and the DON stated the filters were supposed to be checked and cleaned daily.
A resident admitted with respiratory failure, colon cancer, and ileostomy status had physician orders for continuous O2 at 3 L/min via NC, ileostomy care every shift, and wound care to the right groin. The baseline care plan did not include instructions for the ileostomy, oxygen, or wound needs. During observation, the resident had O2 in place, an ileostomy bag, and a dressing to the right groin, and the MDS nurse and DON acknowledged the missing baseline care plan items.
Expired Simethicone was found in a medication aide cart used for the 200- and 300-hall areas during a pharmacy services review. An LVN stated she did not know why the expired medication was still in the cart, and the DON said nurses or medication aides were responsible for removing expired meds from carts per facility policy. The policy required outdated medications to be immediately removed from stock and disposed of according to medication destruction procedures.
Medication storage was not secured when a narcotic box in a 200/300-hall nurse cart was found not permanently affixed and could be removed, with 13 narcotic blister packs inside. In addition, a resident who was sleeping in bed had two bottles of Curad Plain Packing Strip unattended on the nightstand; the RN and DON stated these items should have been stored inside medication carts.
The facility failed to store food in accordance with professional standards when 4 bags of gravy mix in the dry storage room were found without dates showing when they were received. The CDM stated the packages should have been labeled with a date and later said food must be labeled and dated to prevent expired foods from being served.
Undated food items were found in two residents’ personal refrigerators, including cake, a sandwich, milk, and melting ice cream stored in the refrigerator area instead of the freezer area. Both residents had intact cognition and required setup or clean-up assistance with eating, and nursing staff stated the food should have been checked, labeled, and dated when refrigerator temperatures were monitored.
Improper Garbage Disposal Area Maintenance: The facility failed to keep the dumpster area sanitary and properly contained when a bag of trash and broken-down boxes were found on the ground outside the dumpster and the dumpster door was left open. The CDM stated nursing left the trash and boxes there, while dietary was responsible for keeping the area clear and the dumpster closed. The facility policy required garbage to be kept closed when not in use and free from exposed waste.
Surveyors observed a medication cart on the 400 hall left unattended, unsupervised, and unlocked, while staff and residents walked by and residents ambulated in the area. An LVN confirmed the cart belonged to another LVN and contained residents’ injectable insulin and oral medications. The DON later stated that nurses are expected and trained to keep medication carts locked when not in use, and facility policy requires medications to be administered per regulations and good nursing practice, with the cart locked and secured even when preparing PRN doses away from regular med pass.
Several residents, including those with cognitive and physical impairments, were served burnt bread during meals, leading them to refuse the food or request alternatives. Direct observations and resident interviews confirmed the issue, while staff either did not notice the problem or had no response when questioned.
A resident with multiple comorbidities and a history of COVID-19 did not have documentation in the medical record showing that education about the COVID-19 vaccine was provided to the resident or their representative, despite facility policy requiring this step. Staff interviews indicated confusion about vaccine administration, and although consent was obtained, the vaccine was not given and education was not documented.
The facility failed to provide adequate respiratory care for three residents requiring oxygen therapy. Two residents had dusty oxygen concentrators, risking respiratory complications, while a third resident received oxygen without physician orders. The facility's policy on oxygen administration was not followed, leading to these deficiencies.
A resident with multiple health conditions did not receive their ordered PRN hydrocodone for nine days due to a prescription error, despite staff attempts to resolve the issue. The resident was given acetaminophen instead, which was effective for lower pain levels, but the stronger medication was unavailable when needed.
The facility failed to maintain proper food handling and hygiene standards in the kitchen. A dietary staff member handled diet tickets and prepared plates without proper hand hygiene, risking cross-contamination. Additionally, a grilled cheese sandwich was served on a wet divided plate, which was not properly dried, potentially leading to cross-contamination. The dietary supervisor and resource acknowledged these issues, which could make residents sick.
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. One resident's depression was not coded in the annual assessment, and another resident's use of oxygen therapy was omitted. The MDS Coordinator acknowledged these oversights, highlighting the importance of accurate documentation for appropriate care.
The facility failed to include the use of side rails in the care plans of two residents, despite physician orders and observations confirming their use for repositioning and mobility. This omission could lead to staff not monitoring associated risks, potentially resulting in accidents or injuries.
A resident experienced unplanned weight loss due to the facility's failure to follow physician orders for weekly weight monitoring and implement dietary interventions. The resident, admitted with serious medical conditions, was at high risk for nutritional issues. Despite this, the nursing staff did not weigh the resident as required, and there was a lack of communication regarding his reduced appetite. The facility's dietician was not informed of the weight loss in a timely manner, delaying necessary interventions.
The facility failed to assess and document the use of bed rails for two residents before installation. One resident with chronic respiratory failure and another with encephalopathy and moderate cognitive impairment were using side rails without documented assessments or discussions of risks and benefits. The facility's policy requires informed consent and documentation for restraint use, which was not followed.
The facility failed to properly secure drugs and biologicals in two medication carts, with loose, unidentified pills found in the carts. Staff interviews revealed that CMAs are responsible for ensuring carts are clean and free of loose pills, but the presence of these pills could risk residents not receiving their medications as ordered.
The facility failed to maintain an effective training program for staff, specifically for one employee, Cook D, who did not receive required annual trainings. The HR Manager and Administrator rely on the Relias program to track training needs, but Cook D was not identified for overdue trainings. The facility's policy outlines mandatory training topics, but a policy for required annual training was not provided.
The facility failed to provide mandatory effective communication training for an employee, Cook D, as required by their policy. Cook D's training log showed no evidence of annual communication training being completed prior to March 2025, with the last recorded training in January 2024. The HR Manager and Administrator acknowledged the oversight, which could potentially affect residents by leaving them uninformed due to the lack of staff training.
The facility failed to provide mandatory annual dementia management training to an employee, Cook D, as required. Despite being hired in December 2023, Cook D's training log showed no evidence of annual dementia training before March 2025. The HR Manager, responsible for identifying staff needing training, did not include Cook D in the reports. The Administrator confirmed the responsibility of ensuring staff training but could not provide a policy on required training.
The facility failed to provide mandatory QAPI training to an employee, Cook D, as part of its annual training requirements. The training log showed no evidence of QAPI training being provided annually before March 2025, with the last recorded training in January 2024. The HR Manager and Administrator acknowledged their responsibility to ensure staff received annual trainings, but Cook D was not identified in the training program reports. A policy on required annual training was not provided before the survey exit.
The facility failed to provide mandatory annual infection control training to an employee, Cook D, as required by its infection prevention and control program. The HR Manager and Administrator relied on the Relias training program to track compliance but did not identify Cook D as needing training. This oversight could increase the risk of staff errors and potential harm to residents.
The facility failed to provide mandatory ethics training for an employee, Cook D, as required annually. The training log showed no evidence of ethics training being provided prior to March 2025, with the last training completed in January 2024. The HR Manager and Administrator acknowledged their responsibility in ensuring staff received annual trainings, but a policy addressing required training was not provided.
The facility failed to provide required annual behavioral health training for an employee, Cook D, as per regulatory requirements and the facility's assessment. The HR Manager and Administrator relied on the Relias training program to track training needs, but Cook D was not identified for training. Despite requests, no policy on required annual training was provided.
A registered nurse in a long-term care facility diverted narcotic pain medications from two residents, one of whom had been discharged. The facility failed to remove the discharged resident's medication, allowing the nurse to access and misuse it. Additionally, the nurse diverted medication from another resident without proper documentation. The facility's procedures for handling controlled medications for discharged residents were not followed, leading to the oversight.
A resident with dementia and osteomyelitis experienced a change in condition with the onset of diarrhea and a red rash, which was not reflected in her care plan. Despite being at risk for pressure ulcers, the care plan was not updated to address these acute changes. The resident's condition was reported by CNAs, and the NP ordered probiotics and a high fiber diet, but the care plan remained unchanged due to the MDS Nurse's absence.
A resident with severe cognitive impairment and respiratory conditions was not provided adequate oxygen therapy as ordered. Observations revealed the resident with low oxygen saturation levels and an empty oxygen tank. Staff interviews indicated lapses in monitoring and managing the resident's oxygen needs, contrary to the facility's policy and physician's orders.
A facility failed to accurately document the administration of PRN Hydrocodone-Acetaminophen for a resident with dementia and chronic pain. The MAR did not reflect the administration of the medication, despite entries on the Narcotic Count Sheet. This discrepancy was confirmed by the DON, who noted the correct process involves documentation on both the MAR and the Narcotic Count Sheet.
A resident with an abrasion on her elbow did not receive wound care as ordered by the physician, due to a lapse by the Wound Care Nurse who documented the care as completed before performing it and then forgot to administer the treatment. This failure was identified through observations and interviews, revealing that the bandage had not been changed since admission, posing a risk of infection.
A resident's wound care was inaccurately documented as completed in the facility's records, despite the care not being administered. The Wound Care Nurse marked the treatment as done before attempting it and forgot to perform it after failing to locate the resident. The facility lacked a specific policy on clinical record accuracy, leading to this oversight.
Oxygen Therapy Not Provided or Maintained as Ordered
Penalty
Summary
Resident #11 did not receive oxygen at the physician-ordered setting of 5 liters per minute via nasal cannula. The resident was a 63-year-old male with diagnoses including respiratory failure, COPD, and bronchitis, and his care plan included oxygen therapy per physician orders. The physician order dated 03/27/2026 directed continuous oxygen at 5 liters per minute via nasal cannula for COPD. On 05/20/2026 at 9:00 a.m., the resident was observed in bed wearing a nasal cannula connected to the bedside oxygen concentrator, and the concentrator was set at 4.5 liters per minute. During interview, the LVN stated the concentrator was set at 4.5 liters per minute even though the order was for 5 liters per minute, and said she did not know why the resident was receiving 4.5 liters per minute. She stated she had not checked the oxygen rate that shift because she was very busy, although she had checked the resident's oxygen saturation, which was 97%. Resident #32 and Resident #92 also had oxygen concentrators with dirty filters. Resident #32, a cognitively intact female with COPD, pleural effusion, and tachycardia, had an order for oxygen at 3 liters per minute as needed; Resident #92, a cognitively intact female with COPD, pneumonia, legal blindness, and heart failure, had an order for oxygen at 3.5 liters per minute continuously. On 05/17/2026, surveyors observed both residents using oxygen via nasal cannula while the filters in the back of their concentrators were dirty. On later observations, the filters remained dirty. RN E stated night shift was responsible for cleaning the filters daily and that nurses caring for residents on oxygen were supposed to check them. The DON stated it was night shift's responsibility to check and clean the filters every day.
Missing Baseline Care Plan for Ileostomy, Oxygen, and Wound Care
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #123 that included instructions for ileostomy care, oxygen care, and wound care. Resident #123 was a 71-year-old male admitted with diagnoses including respiratory failure, malignant neoplasm of the colon, and ileostomy status. His physician orders dated 05/15/2026 included monitoring and providing ileostomy care every shift, oxygen at 3 liters per minute via nasal cannula continuously for COPD, and wound care to the right groin twice weekly with wound cleanser, plurogel, calcium alginate, and a bordered foam dressing. Record review showed the baseline care plan dated 05/17/2026 did not include the resident’s ileostomy, oxygen, or wound care needs. Observation on 05/17/2026 at 10:45 a.m. showed the resident sleeping in bed with oxygen at 3 liters per minute via nasal cannula, an ileostomy bag on the abdomen, and a dressing dated 05/19/2026 to the right groin area. The MDS nurse stated the resident was admitted with ileostomy, oxygen, and wound needs and that the facility provided the ordered care, but there were no baseline care plans for those needs. The DON stated she should have developed the baseline care plans because the resident was admitted with them and said the team might not have full knowledge regarding the resident’s ileostomy, oxygen, and wound status.
Expired Medication Found in Medication Cart
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when an expired bottle of Simethicone 125 mg for gas relief was found inside the 200 and 300-hall medication aide cart. The medication was observed in the cart on 05/18/2026 and had expired in 03/2026. The finding involved 1 of 6 medication carts reviewed for pharmacy services. During interview, LVN-B stated the expired Simethicone was found in the 200 and 300-hall medication aide cart and said she did not know why it was there. She stated nurses and medication aides should discard expired medications from the carts according to facility policy. The DON also stated nurses or medication aides were responsible for removing expired medications from medication carts. The facility policy, Medication Access and Storage, stated outdated medications are to be immediately removed from stock and disposed of according to medication destruction procedures.
Medication Storage and Controlled Substance Security
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments for 1 of 6 medication carts reviewed. During observation on 05/18/2026 at 2:30 p.m., the narcotic box inside the 200/300-hall nursing cart was found not permanently affixed to the cart and was taken out by the surveyor. The box contained 13 narcotic blister packs. LVN-B stated the narcotic box should have been permanently affixed to the cart and that it was not secured, allowing someone to take it from the cart and potentially cause drug diversion. The DON stated that all narcotic boxes should be affixed to the carts permanently to prevent possible drug diversion. The facility also failed to ensure medications were stored in locked compartments for 1 of 28 residents reviewed. Resident #123 was a 71-year-old male admitted with respiratory failure, malignant neoplasm of the colon, and ileostomy status, and his MDS assessment was in progress because he had recently been admitted. On 05/17/2026 at 10:45 a.m., the resident was observed sleeping in bed with two bottles of Curad Plain Packing Strip for wound care unattended on his nightstand. RN-C stated she saw the packing strips on the nightstand and did not know why they were there, and said medications should have been stored inside medication carts for safety. The DON stated that all medications, including Curad Plain Packing Strip for wound care, should have been stored inside medication carts for safety.
Undated Dry Storage Food Items
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed. During an observation in the dry storage room, 3 bags of chicken gravy mix and 1 bag of pork gravy mix were found without dates showing when the packaged gravy mixes were received. During an interview, the CDM stated that the bags should have been labeled with a date and removed the bags from the shelf, and later stated that food should be labeled and dated to prevent expired foods from being served. Record review of the facility policy did not reveal information on how dry foods should be stored, and the referenced Texas Health and Human Services guidance stated that dry food storage is clean, covered/sealed, labeled, and dated.
Undated Food Items Stored Improperly in Resident Refrigerators
Penalty
Summary
The facility failed to follow its policy regarding the use and storage of foods brought to residents by family and other visitors for 2 of 28 residents reviewed. On 05/17/2026, Resident #11, a 63-year-old male with diagnoses including respiratory failure, COPD, and bronchitis, was observed with a personal refrigerator in his room containing one piece of cake, a sandwich, and one cup of milk, with no dates on the food. His quarterly MDS dated 05/11/2026 showed a BIMS score of 13 out of 15, indicating intact cognition, and he required setup or clean-up assistance with eating. His care plan identified a risk for malnutrition related to diabetes and included a regular diet with thin liquids. Also on 05/17/2026, Resident #43, a 73-year-old female with diagnoses including a left humerus fracture, conversion disorder, and hypertension, was observed with a small refrigerator in her room containing melting ice cream in the refrigerator area instead of the freezer area, with no date on it. Her admission MDS dated 4/30/2026 showed a BIMS score of 14 out of 15, indicating intact cognition, and she required setup or clean-up assistance with eating. Her care plan identified a potential nutritional problem related to weakness and included a regular diet with thin liquids. Interviews with nursing staff indicated the food items had no dates and that the nurse should have checked the food when checking refrigerator temperatures and labeled and dated the items.
Improper Garbage Disposal Area Maintenance
Penalty
Summary
The facility failed to ensure that garbage and refuse containers were in good condition, that waste was properly contained in dumpsters or compactors with lids or otherwise covered, and that the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pests for 1 of 1 garbage disposal areas reviewed. During an observation on 5/17/2026 at 9:55 AM, the dumpster outside was in an enclosed area, and when the DM opened the doors, a bag of garbage was observed on the ground, boxes were broken down on the ground, and the dumpster door was open. The CDM stated that the nursing side had left the bag of garbage and boxes on the ground, and that dietary was responsible for making sure no garbage was on the ground and that the dumpster door was closed. During an interview on 5/20/2026 at 11:34 AM, the CDM stated it was important to keep trash off the ground and keep the dumpster door closed to prevent infestation of pests and rodents that could cause food contamination and food borne illness of the residents if they entered the building. The facility policy titled, Garbage Disposal and Dumpster Sanitation, stated that garbage was to be kept closed when not actively in use, free from overflow, excess buildup, or exposed waste, and that staff must close lids immediately after depositing trash.
Unattended, Unlocked Medication Cart with Insulin and Oral Medications
Penalty
Summary
The deficiency involves a failure to ensure that drugs and biologicals were stored in locked compartments with access limited to authorized personnel. During an observation on 4/28/2026 at 9:10 AM, the 400-hall medication cart was found positioned at the beginning of the hall, unattended, unsupervised, and unlocked. Continued observation showed two staff members walking past the unlocked cart without noticing its unsecured status, while residents were observed ambulating in the facility, including the 400-hall. The State Surveyor intervened and notified an LVN, who identified the cart as the 400-hall medication cart assigned to another LVN and stated that it contained residents’ injectable insulin and oral medications. In an interview later that morning, the DON stated that her expectation and nurse training were that nurses lock their medication carts when the cart is not in use, and she identified the potential negative outcome as uncontrolled medications. A review of the facility’s undated “Medication Administration and General Guidelines” policy showed that medications are to be administered as prescribed, in accordance with state regulations and good nursing principles, and only by persons legally authorized to do so. The policy further specified that when administering PRN medications at times other than a medication pass, doses may be prepared in the medication cart storage area and taken to the resident’s bedside, with the cart remaining locked and secured. The observed unlocked, unattended cart containing medications was inconsistent with this policy and the DON’s stated expectations.
Failure to Provide Palatable Food During Meals
Penalty
Summary
Surveyors found that the facility failed to provide palatable food to residents, as evidenced by multiple instances where residents were served burnt bread during meals. Specifically, three residents with varying medical conditions, including hemiplegia, dysphagia, dementia, diabetes, Alzheimer's disease, and muscular dystrophy, were observed during lunch receiving Italian rolls that were burned at the bottom. Two residents directly stated they would not eat the bread due to it being burnt, and another resident reported that burned food was a recurring issue, often leading them to forgo eating or request alternatives. These findings were based on direct observation, resident interviews, and review of medical records and care plans, which indicated that all affected residents were on regular diets and, in some cases, required assistance with meal setup or supervision. When the issue was brought to the attention of facility staff, the DON had no response regarding the burnt bread, and the Food Service Manager, who assisted with the meal, stated she did not notice any burnt bread or receive complaints. The facility's policy provided to surveyors referenced the Texas Food Establishment Rules. The deficiency was identified as a failure to provide food that was palatable and met the needs of each resident, as required.
Failure to Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to implement its COVID-19 immunization policies and procedures by not ensuring that a resident's medical record included documentation that the resident or their representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. Record review showed that the resident had a history of heart failure, acute respiratory failure, dementia, cognitive communication deficit, and required personal assistance. The resident had previously contracted COVID-19 and had received her last COVID-19 vaccination in late 2023. However, there was no documentation in the care plan or medical record indicating that education about the COVID-19 vaccine was provided to the resident or her representative during the relevant period. Interviews with facility staff, including the DON and previous ADON, revealed uncertainty about the ongoing administration of COVID-19 vaccines to residents. The resident's responsible party confirmed that consent for vaccination had been given, but the vaccine was not administered, and no education was provided. The facility's policy required that education be provided and documented before offering the vaccine, but this was not followed for the resident in question.
Inadequate Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents who required oxygen therapy. For two residents, the nursing staff did not regularly clean the oxygen concentrators, which were observed to be covered in dust, including the vent ports where filters are located. This lack of maintenance could lead to the residents inhaling dust particles, potentially causing infections or respiratory complications. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that the concentrators were not being cleaned as required, and there was uncertainty about whether the rental company serviced the equipment. For the third resident, the facility did not have physician orders for the use of oxygen, despite the resident being observed with oxygen therapy on multiple occasions. The resident's care plan did not include any focus or interventions for oxygen therapy, and the nursing staff was unaware of the need for a physician's order. The DON acknowledged that the resident should have had orders for oxygen use, as it had been administered without proper documentation or guidance. The facility's policy on oxygen administration requires that oxygen therapy be administered as ordered by a physician or as an emergency measure until an order can be obtained. However, this policy was not followed, leading to the deficiencies observed. The lack of proper maintenance and documentation for oxygen therapy placed the residents at risk of respiratory complications.
Failure to Provide Ordered PRN Hydrocodone for Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically by not having the ordered PRN hydrocodone available for nine days from admission to discharge. The resident, a male with diagnoses including metabolic encephalopathy, acute pulmonary edema, and a stage III pressure ulcer, was moderately cognitively impaired and required PRN pain medication. Despite having an order for hydrocodone, the medication was not available, and the resident did not receive it during his stay. The deficiency was identified through interviews and record reviews, which revealed that the facility did not have an active prescription for the hydrocodone on file with the pharmacy. Attempts by nursing staff to obtain the medication from the emergency kit were denied due to the lack of a prescription. The physician had sent the prescription multiple times, but it was not received by the pharmacy due to an error in the submission process. As a result, the resident was given acetaminophen instead, which was effective for lower pain levels, but the stronger medication was unavailable when requested by the family. Interviews with staff indicated that there were ongoing issues with obtaining the hydrocodone, and the resident was observed to be in pain on at least one occasion. The Director of Nursing stated that the expectation was for nurses to notify the physician and pharmacy if a medication was unavailable. The facility's policy emphasized the importance of providing pharmaceutical services to meet residents' needs, but this was not achieved in this case, leading to the deficiency.
Improper Food Handling and Hygiene in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. A dietary staff member, after washing hands, handled diet tickets and then proceeded to prepare resident plates without maintaining proper hand hygiene. The staff member was seen placing fingers inside bowls and plates, which could lead to cross-contamination. The dietary supervisor acknowledged that meal tickets are not considered clean items and that improper handling of bowls and plates could cause cross-contamination. Additionally, a divided plate was observed with water droplets and pooling water, which was not properly dried before a grilled cheese sandwich was served on it. The dietary supervisor and resource acknowledged that serving food on wet plates could lead to cross-contamination and potentially make residents sick. The facility's policy on handling clean equipment and utensils was reviewed, which stated that clean items should be handled to prevent contamination, and dishes should be air-dried and inspected for cleanliness and dryness before use.
Inaccurate Resident Assessments Lead to Deficiencies
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. For one resident, the nursing staff did not code a diagnosis of depression on the resident's annual assessment, despite documentation in the psychiatric initial assessment and reports from the resident's family indicating the resident was experiencing depression. The MDS Coordinator acknowledged the oversight and emphasized the importance of accurately reflecting the resident's status to ensure appropriate care and services. In another case, the nursing staff failed to document that a resident was receiving oxygen therapy on her annual assessment, even though physician orders and the care plan indicated the use of oxygen due to a respiratory illness. Observations confirmed the resident was using oxygen, and the MDS Coordinator admitted the omission in the assessment. This failure to accurately document the resident's status could lead to inadequate care and services being provided.
Failure to Include Side Rails in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which included measurable objectives and timeframes to meet their medical and nursing needs. For one resident, who was admitted with chronic respiratory failure and chronic pulmonary edema, the care plan did not reflect the use of side rails for repositioning and mobility, despite physician orders indicating their use. Observations confirmed the presence of side rails, and interviews with the MDS Coordinator revealed that the omission could lead to staff not monitoring associated risks, potentially resulting in accidents or injuries. Similarly, another resident, admitted for orthopedic aftercare following a surgical amputation, also had physician orders for the use of side rails for mobility and repositioning. However, the care plan failed to document this need. Observations and interviews confirmed the resident's use of side rails, and the MDS Coordinator acknowledged that the care plan should have included this information to ensure staff awareness and risk monitoring. The facility's policy mandates that care plans include measurable objectives and timeframes to address residents' needs, which was not adhered to in these cases.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by the case of a resident who experienced unplanned weight loss. The nursing staff did not follow physician orders to weigh the resident weekly for four weeks, which was crucial for monitoring his nutritional status. Additionally, dietary interventions were not implemented when the resident's weight began to trend downward, despite the resident being identified as at risk for weight loss. The resident, who had been admitted with diagnoses including encephalopathy, respiratory failure, and sepsis, was at risk for nutritional issues due to his medical condition. His nutritional risk evaluation indicated a high risk, necessitating immediate preventive protocols. However, the resident's care plan and progress notes did not reflect adequate monitoring or intervention, as his weight decreased from 129.58 pounds to 124.9 pounds within a short period. The resident's meal intake varied, and there was a lack of communication between the CNA and nursing staff regarding his reduced appetite and meal consumption. Interviews with facility staff revealed systemic issues in communication and protocol adherence. The LVN was unaware of the resident's high risk for weight loss and did not realize the resident's weight was trending down until it was too late. The facility's dietician was not informed of the resident's weight loss in a timely manner, delaying necessary dietary interventions. The DON acknowledged broken systems within the facility, including the failure to audit resident records and discuss significant events like weight loss. The facility's policy required regular weight monitoring and intervention, but these procedures were not followed, leading to the resident's unplanned weight loss.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for two residents, Resident #85 and Resident #95, prior to their installation. Resident #85, who was admitted with chronic respiratory failure and pulmonary edema, had an order for mobility bars to aid in repositioning but lacked an assessment for the use of side rails. There was no documentation indicating that the risks and benefits of using side rails were discussed with the resident, who had no cognitive impairment as per her BIMS score. Interviews with facility staff confirmed the absence of an assessment and discussion regarding the use of side rails. Resident #95, admitted with encephalopathy, respiratory failure, and sepsis, also had an order for mobility bars. His admission MDS assessment indicated moderate cognitive impairment. Observations revealed that he used quarter side rails, but he did not recall any discussion about their use. The facility's Director of Nursing confirmed that staff were required to conduct assessments and discuss the risks and benefits of side rails with residents or their representatives, which was not done in this case. The facility's policy mandates that residents have the right to be free from restraints unless necessary to treat medical symptoms, and requires a physician's order and informed consent for their use. The policy also emphasizes the need for ongoing assessments and documentation of medical symptoms warranting restraint use. The failure to adhere to these procedures could potentially lead to avoidable injuries for residents using side rails.
Improper Storage of Medications in Medication Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly secured within two of the four medication carts observed for medication storage. Specifically, one unidentified small round white pill was found in the bottom drawer of the medication cart on the 400 hall, and two unidentified small round white pills were found in the top drawer of the medication cart on the 300 hall. These pills were loose, unlabeled, and lacked identifying markers, although the medication carts themselves were locked and secured. Interviews with staff revealed that the Certified Medication Aide (CMA) could not identify the loose pills and stated that facility policy requires staff to dispose of any loose pills found in medication carts. The Director of Nursing (DON) confirmed that medications are to be stored in their original packaging and that CMAs are responsible for checking the carts daily to ensure cleanliness and the absence of loose pills. Despite this, the presence of loose pills in the medication carts was observed, which could potentially lead to residents not receiving their necessary medications as ordered.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, specifically for one employee, Cook D, out of 28 employees reviewed for training requirements. The personnel records for Cook D showed a hire date of December 16, 2023, but the training log provided by the HR Manager revealed no evidence of required annual trainings being completed prior to March 25, 2025. The missing trainings included communication, resident rights, QAPI, infection control, ethics, behavior health, dementia, HIV, falls, restraint, and emergency preparedness training. The last recorded completion of these trainings was in early 2024, indicating a lapse in maintaining the annual training schedule. Interviews with the HR Manager and Administrator revealed that the facility relies on the Relias training program to identify staff needing annual trainings within 30 days. However, Cook D did not appear on any weekly reports generated by the HR Manager, who acknowledged it was his responsibility to run these reports and provide them to department heads. The Administrator confirmed that it is the responsibility of HR and department heads to ensure staff complete their trainings to maintain quality care. The facility's policy on in-service training, dated April 2004, outlines mandatory training topics, but a policy addressing required annual training for specific areas was not provided upon request.
Failure to Provide Mandatory Communication Training
Penalty
Summary
The facility failed to provide mandatory effective communication training for one of its employees, Cook D, as required by their training policy. Cook D was hired on December 16, 2023, and a review of their training log from the previous 15 months showed no evidence of annual communication training being completed prior to March 25, 2025. The last recorded completion of this training was on January 25, 2024. This oversight in training could potentially affect residents by leaving them uninformed due to the lack of staff training. Interviews with the HR Manager and the Administrator revealed that the facility relied on the Relias training program to identify staff who needed to complete annual trainings. The HR Manager was responsible for running weekly reports to identify employees with upcoming training due dates and providing these reports to department heads. However, Cook D did not appear on any of these reports, leading to the missed training. Both the HR Manager and the Administrator acknowledged that failing to train staff annually increased the risk of staff errors, potentially putting residents in harm's way. The facility's policy mandates that all employees attend training on various topics, including communication skills, to ensure quality care is provided.
Failure to Provide Annual Dementia Training
Penalty
Summary
The facility failed to provide mandatory dementia management training to one of its employees, Cook D, as required annually. Cook D was hired on December 16, 2023, and a review of their training log from the previous 15 months showed no evidence of dementia training being provided annually before March 25, 2025. The last recorded dementia training for Cook D was completed on January 26, 2024. This oversight was identified during an interview with the HR Manager, who stated that the facility relied on the Relias training program to identify staff needing annual training within 30 days. However, Cook D did not appear on any of the weekly reports generated by the HR Manager, who acknowledged it was his responsibility to run these reports and provide them to department heads to ensure staff completed their required training. The Administrator confirmed that both HR and the Administrator were responsible for ensuring staff received their annual training. The Administrator also stated that department heads were tasked with ensuring their staff completed the necessary training to maintain quality care. Despite requests, a policy addressing required annual training, including dementia training, was not provided by either the HR Manager or the Administrator before the exit. The lack of training could potentially place residents at risk due to staff being uninformed.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to include mandatory training on its Quality Assurance and Performance Improvement (QAPI) program for one of its employees, Cook D, as part of its annual training requirements. The personnel records for Cook D showed a hire date of December 16, 2023, and a review of the training log for the previous 15 months revealed no evidence of QAPI training being provided annually before March 25, 2025. The last recorded QAPI training for Cook D was completed on January 26, 2024. Interviews with the HR Manager and the Administrator revealed that the facility relied on the training program Relias to identify staff who had annual trainings due within 30 days. The HR Manager stated that Cook D did not appear on any of the weekly reports generated to track training compliance. Both the HR Manager and the Administrator acknowledged their responsibility to ensure staff received their annual trainings, emphasizing that failure to do so could increase the likelihood of staff errors and put residents at risk. Despite requests, a policy addressing required annual training, including QAPI training, was not provided by either the HR Manager or the Administrator before the survey exit.
Failure to Provide Annual Infection Control Training
Penalty
Summary
The facility failed to provide mandatory infection prevention and control training to one of its employees, Cook D, as part of its infection prevention and control program. The personnel records for Cook D showed a hire date of December 16, 2023, and a review of the training log for the previous 15 months revealed no evidence of annual infection control training being provided prior to March 25, 2025. The last recorded annual infection control training for Cook D was completed on January 26, 2024. Interviews with the HR Manager and the Administrator revealed that the facility relied on the training program Relias to identify staff who needed to complete annual trainings. The HR Manager stated that Cook D did not appear on any of the weekly reports generated by Relias, which are used to track training compliance. Both the HR Manager and the Administrator acknowledged their responsibility in ensuring staff received their annual trainings, emphasizing that failure to do so could increase the risk of staff performing tasks incorrectly and potentially harming residents.
Failure to Provide Mandatory Ethics Training
Penalty
Summary
The facility failed to provide mandatory ethics training for one of its employees, Cook D, as required annually. The personnel records for Cook D showed a hire date of December 16, 2023, and a review of the training log from the previous 15 months revealed no evidence of ethics training being provided annually prior to March 25, 2025. The last recorded ethics training for Cook D was completed on January 25, 2024. This lapse in training was identified during an interview with the HR Manager, who stated that the facility relied on the training program Relias to identify staff who had annual trainings due within 30 days. However, Cook D did not appear on any of the weekly reports generated by Relias, which the HR Manager was responsible for running and distributing to department heads. The HR Manager acknowledged that it was his responsibility to ensure that department heads were informed of staff needing to complete their trainings. The Administrator confirmed that both HR and the Administrator were responsible for ensuring staff received their annual trainings. The Administrator emphasized that staff were required to complete trainings to stay updated on policies and procedures to ensure quality care. Despite requests, a policy addressing required annual training, including ethics training, was not provided by either the HR Manager or the Administrator before the exit interview.
Failure to Provide Required Behavioral Health Training
Penalty
Summary
The facility failed to provide behavioral health training consistent with regulatory requirements and the facility's own assessment for one employee, Cook D, out of 28 employees reviewed. Cook D's personnel records showed a hire date of December 16, 2023, and a training log review revealed that the last annual behavioral health training was completed on January 26, 2024. There was no evidence of the required annual training being provided prior to March 25, 2025. This oversight was identified during an interview with the HR Manager, who acknowledged the reliance on the Relias training program to track and notify staff of upcoming training requirements. The HR Manager admitted that Cook D did not appear on any of the weekly reports generated by Relias, which are used to identify employees needing to complete annual trainings. The HR Manager and the Administrator both stated that it was their responsibility to ensure staff received their annual trainings, and that department heads were responsible for ensuring their staff completed these trainings. Despite requests, a policy addressing required annual training, including behavioral health training, was not provided by either the HR Manager or the Administrator before the survey exit.
Medication Diversion by RN in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, specifically involving the diversion of narcotic pain medications by a registered nurse (RN-B). After a resident was discharged, the facility did not remove the resident's medication blister pack of Hydrocodone/Acetaminophen from the medication cart, which allowed RN-B to divert eight tablets for personal use. This oversight occurred despite the resident being discharged, and the medication continued to be documented as administered by RN-B. Another resident's medication was also misappropriated by RN-B, who diverted five tablets of Hydrocodone/Acetaminophen for personal use. The narcotic count sheets indicated that these medications were signed off by RN-B, but they were not documented on the resident's Medication Administration Record (MAR). The resident, however, did not report any pain or issues with receiving pain medication when needed. The facility's process for handling controlled medications for discharged residents was not followed correctly, as the medications remained in the cart and were not removed by the Director of Nursing (DON) as required. The narcotic counts were conducted at shift changes, but discrepancies were not identified, and the discharged status of the resident was not recognized. This failure in procedure allowed RN-B to continue accessing and diverting the medications without detection until an audit revealed the issue.
Failure to Update Care Plan for Resident with Diarrhea and Skin Breakdown
Penalty
Summary
The facility failed to review and revise the care plan for Resident #4 after a change in her condition, specifically regarding her bowel incontinence and increased risk for skin breakdown. Resident #4, an elderly woman with dementia, pleural effusion, and osteomyelitis, was initially assessed as being at risk for pressure ulcers. Despite this, her care plan was not updated to address the development of diarrhea and a red rash in her peri-area, buttocks, and sacrum. The resident experienced a change in condition with the onset of diarrhea, which was reported by CNAs to the nursing staff. The diarrhea was attributed to antibiotic therapy, and despite the administration of Imodium, the condition persisted. The resident developed a red rash and was in significant discomfort, which was noted by the CNAs and reported to the nursing staff. The NP was aware of the diarrhea and ordered probiotics and a high fiber diet, but was not informed of the pressure ulcer development. The Wound Care Nurse was aware of the moisture-associated skin damage and was treating it with Triad paste, but the care plan was not updated to reflect these acute changes. The Director of Nursing acknowledged that the care plan should have been updated to address the resident's acute changes, but the MDS Nurse responsible for updating care plans was on vacation and unaware of the rapid onset of the resident's condition.
Inadequate Respiratory Care for Resident
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required oxygen therapy, as evidenced by multiple observations and interviews. The resident, who had severe cognitive impairment and a history of metabolic encephalopathy, severe sepsis with septic shock, and pneumonia, was observed with an oxygen saturation level of 83% on room air, which is below the preferred level of 90% or higher. Despite having a physician's order for oxygen therapy at 2-4 liters per minute as needed, the resident was found without oxygen in the dining room and later with an empty oxygen tank in her room. Interviews with the resident's family and staff revealed inconsistencies in the administration of oxygen therapy. The family member reported that the resident was found without oxygen and had a low oxygen saturation level, prompting staff to provide an oxygen tank. A Licensed Vocational Nurse (LVN) acknowledged that the resident's oxygen tank was empty and should have been replaced or the resident should have been connected to the oxygen concentrator upon returning to her room. The LVN admitted to not paying sufficient attention to the oxygen tank levels and stated that oxygen saturation levels were checked only once per shift. The Director of Nursing (DON) and a nurse practitioner confirmed the importance of maintaining oxygen saturation levels above 90% to prevent poor oxygenation and altered mental status. The facility's policy on oxygen administration emphasized the need for oxygen therapy to be administered as ordered by the physician. However, the failure to consistently monitor and manage the resident's oxygen therapy led to inadequate treatment, as evidenced by the resident's low oxygen saturation levels and the use of an empty oxygen tank.
Inaccurate Documentation of PRN Medication Administration
Penalty
Summary
The facility failed to maintain accurate clinical records for a resident regarding the administration of PRN medication, Hydrocodone-Acetaminophen, over five instances in February and March 2024. The medication administration records (MAR) did not reflect the administration of this medication, despite entries on the Narcotic Count Sheet indicating that the medication was given. This discrepancy was confirmed during an interview with the Director of Nursing (DON), who noted that the correct process involves documenting the administration of PRN medication on both the MAR and the Narcotic Count Sheet. The resident involved was a woman with a history of dementia, spinal fractures, and chronic pain, who was prescribed Norco for severe pain. The lack of documentation on the MAR could lead to improper medication administration and hinder accurate tracking of the resident's pain management needs. The DON acknowledged the issue and noted that the problem of inaccurate documentation had been identified previously, leading to the implementation of a new auditing process by the Assistant Directors of Nursing (ADONs).
Failure to Administer Wound Care as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, specifically in administering wound care as ordered by the physician. The resident, who was admitted with conditions including atherosclerotic heart disease, high blood pressure, and cognitive communication deficit, had an abrasion on her right elbow that required dressing changes every Monday, Wednesday, and Friday. However, the wound care was not performed as scheduled. On one occasion, the Wound Care Nurse documented that the care was completed before actually performing it, and subsequently forgot to administer the treatment after being unable to locate the resident. This oversight was confirmed through interviews and observations, where it was noted that the bandage on the resident's elbow had not been changed since the date of admission. The Wound Care Nurse admitted to checking off the wound care in the electronic clinical record prematurely and acknowledged forgetting to return to complete the task. The Director of Nursing and the Administrator both recognized the potential harm of not providing wound care as ordered, which could disrupt the healing process and increase the risk of infection.
Inaccurate Wound Care Documentation
Penalty
Summary
The facility failed to maintain accurate clinical records for a resident, specifically regarding wound care documentation. The resident, who was admitted with conditions including atherosclerotic heart disease, high blood pressure, and cognitive communication deficit, had an order for wound care on her right elbow. The treatment administration record inaccurately documented that wound care was completed when it had not been provided. This discrepancy was discovered when the resident was observed with a bandage dated several days prior, indicating the wound care had not been performed as documented. Interviews revealed that the Wound Care Nurse had preemptively marked the wound care as completed in the electronic record before attempting to perform the care. The nurse was unable to find the resident in her room and subsequently forgot to administer the treatment. The Director of Nursing and the Administrator acknowledged the failure to follow the facility's standard of practice, and it was noted that the facility lacked a specific policy on the accuracy of clinical records. The existing guidance from the corporate manual emphasized timely and accurate documentation, which was not adhered to in this instance.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 315 citations issued within 25 miles in the last 12 months — including the 5 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Braunfels
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At New Braunfels | 1 mi | ★★★★★ | 38 | 2 |
| Sundance Inn Health Center | 2 mi | ★★★★★ | 16 | 0 |
| Eden Home | 3.9 mi | ★★★★★ | 23 | 0 |
| Kirkwood Manor | 5.8 mi | ★★★★★ | 19 | 0 |
| Cypress Healthcare And Rehabilitation Center | 11 mi | ★★★★★ | 2 | 0 |
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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.