Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 - North during CMS and state inspections, most recent first.
Staff entered the rooms of three residents without knocking first. Observations showed HK G and a CNA going into resident rooms without announcing themselves, and interviews confirmed the residents noticed unannounced entries and wanted staff to knock before coming in. The DON and ADM stated that knocking before entry is part of resident rights and is required to protect privacy and respect.
Improper Portioning of Pureed Diet Menus: CK F served pureed meals using scoop sizes that did not match the posted menu for several residents on pureed diets. A resident with stroke, dysphagia, and weight loss, a resident with Parkinson's disease and dementia, and a resident with dementia and anorexia were all ordered pureed diets, yet breakfast and lunch observations showed smaller scoops than the menu required. The DS said staff were taught the scoop colors and numbers and checked the diet spreadsheet, while the DON and ADM acknowledged the menu and portioning issues.
A facility failed to keep call lights within reach for four residents who needed staff assistance. One resident with OA, carpal tunnel syndrome, and age-related cognitive decline, one resident with hemiplegia, epilepsy, and cognitive communication deficit, one resident with dementia and cognitive communication deficit, and one resident with hemiplegia and Parkinson's disease were observed in bed with call lights wrapped around the bedframe, hanging off the bed, or on the floor and out of reach. Staff interviews confirmed that call lights are supposed to be placed within residents' reach before leaving the room.
Failure to Provide Incontinent Care After Transfer Out of Bed: A resident with intact cognition and dependence for toileting hygiene, bed mobility, and transfers reported that staff would get her up in the morning but would not provide incontinent care until she returned to bed later in the day. A CNA said he changed residents every 2 hours but did not change this resident again after getting her up, and he did not ask if she needed care. The DON and ADM stated staff were responsible for checking and providing incontinent care as needed, and observations showed the resident received care when transferred out of bed and again when she went back to bed.
A resident with multiple chronic conditions, including difficulty walking and unsteadiness on feet, did not receive timely podiatry care after admission. Staff noted very long, thick toenails that could not be trimmed by nursing, while the resident reported severe foot pain and said he had not seen a podiatrist. The SW said insurance authorization delayed the referral process, and the NP, DON, and ADM acknowledged the resident had not been seen until the issue was addressed later.
Medication administration was not completed as required for two residents. One resident with dementia and moderate cognitive impairment had pills left on her bedside table during breakfast, and another resident with dementia had an Albuterol HFA inhaler left on her bedside table. Staff interviews confirmed that medication was not to be left with residents and that staff were supposed to remain with the resident until the medication was swallowed; neither resident had a self-administration assessment.
A resident with severe dementia and total dependence on staff suffered a fractured thumb during a brief change by two CNAs, who proceeded with care despite the resident's refusal and were heard causing pain. The incident was not immediately reported, and video evidence showed staff drawing a curtain to block the camera during the event. The injury was later confirmed at the hospital, and the facility failed to follow its abuse reporting protocols.
A resident with severe cognitive impairment and total dependence on staff sustained a comminuted fracture of the right thumb during care provided by two CNAs, who blocked camera visibility and did not report the injury. The facility failed to implement effective abuse prevention policies, did not document or explain the injury, and did not ensure timely reporting, resulting in an Immediate Jeopardy finding.
A resident with severe cognitive impairment and multiple health conditions was found with a significant bruise and swelling to her right thumb of unknown origin. The injury was first identified during a skin assessment, and interviews indicated that two CNAs were present at the time the resident cried out in pain. Despite the facility's policy and regulatory requirements for immediate reporting, the incident was not reported to state authorities within the mandated timeframe.
A resident with multiple medical conditions and moderate cognitive impairment missed a scheduled surgical appointment after being mistakenly left behind, while another resident was transported in error. The driver failed to verify the resident's identity using the face sheet or by consulting with nursing staff, instead relying on a CNA's verbal confirmation. The facility lacked a written policy for resident identification prior to outside appointments, resulting in this deficiency.
A resident with multiple medical conditions experienced an ongoing ant infestation in their bedroom, leading to discomfort and suspected insect bites. Despite scheduled pest control visits and staff training on reporting pests, the issue persisted, and the resident required medical attention. Facility policy required prompt reporting and intervention, but the pest control program was not effectively implemented.
A resident's representative was not provided with requested medical records despite submitting the required authorization. The request was delayed due to miscommunication among staff and lack of follow-up after legal approval, and facility policies did not specify procedures or time frames for processing such requests. The resident had severe cognitive impairment, highlighting the importance of representative access.
The facility failed to provide dignified meal service for three residents, including one who was left unattended with a meal tray despite needing assistance, and two others who received their meals later than their tablemates. Staff interviews revealed awareness of policies requiring simultaneous meal service and assistance for residents, yet these were not followed, compromising resident dignity and quality of life.
The facility failed to provide adequate ADL care for several residents, resulting in untrimmed nails and poor hygiene. A resident with Parkinson's and another with diabetes had long, unmaintained nails, while another resident was observed with a strong urine odor due to inadequate toileting assistance. Staff interviews revealed inconsistencies in care provision.
The facility failed to ensure residents had adequate access to a working call light system, as observed in two cases. A resident with multiple health issues and a recent fracture had his call light out of reach, contrary to his care plan. Another resident with limited hand mobility also reported her call light was frequently inaccessible. Staff interviews confirmed the importance of call light accessibility, yet the facility's policy was not consistently followed, risking unmet needs and potential harm.
A facility failed to maintain an effective infection control program, leading to improper incontinent care and lack of PPE use for two residents. One resident received inadequate perineal care, while another did not have necessary PPE during high-contact care activities. Staff interviews revealed a lack of adherence to infection control protocols, and the absence of signage and PPE bins further contributed to the deficiency.
A resident with severe cognitive impairment was transferred by a CNA using a mechanical lift without the required assistance of a second staff member, contrary to the care plan. This placed the resident at risk of injury, as the facility's policy required two-person assistance for such transfers.
A resident with severe cognitive impairment and dysphagia consistently refused or spit out medications, but the facility failed to notify the NP as required by policy. Despite staff awareness of the issue, the NP was not informed, leading to a deficiency in care.
Two CNAs failed to follow infection control protocols during peri care for two residents, leading to contamination of personal care items and surfaces. One resident, a male with cognitive impairment and incontinence, was cared for by a CNA who did not sanitize her hands or the wheelchair surface. The other resident, a female with severe cognitive impairment, was cared for by a CNA who also failed to sanitize her hands and contaminated various items. Both CNAs acknowledged their mistakes, and the DON emphasized the importance of proper hand hygiene.
The facility failed to ensure call buttons were within reach for three residents, compromising their ability to request assistance. A resident with severe cognitive impairment found her call button on the floor, another with intact cognition had her call button under the mattress, and a third with moderate cognitive impairment had his call button on the floor out of reach. Staff acknowledged the oversight, and the DON confirmed the importance of accessible call buttons.
A resident with severe cognitive impairment was transferred by a CNA using a mechanical lift without the required assistance of a second staff member, contrary to the facility's policy and training. Despite training and performance reviews emphasizing the need for two staff members during transfers, the CNA conducted the transfers alone, placing the resident at risk of injury.
Staff Entered Resident Rooms Without Knocking
Penalty
Summary
The facility failed to care for residents in a manner and in an environment that promotes maintenance or enhancement of quality of life for three residents when staff did not knock before entering their rooms. Observation on the 200-hall showed HK G entering Resident #31's and Resident #106's rooms without knocking, and observation on the 300-hall showed CNA H entering Resident #3's room without knocking while lunch trays were being passed. The report states that this practice could place residents at risk of feeling like their privacy is being invaded or that the facility is not their home. Resident #3 was a male readmitted to the facility with diagnoses including other acute osteomyelitis of the left ankle and foot, type 2 diabetes mellitus, and schizoaffective disorder. His quarterly MDS showed a BIMS score of 15, indicating intact cognitive response, and his care plan identified him as at risk for falls related to gait and balance issues, decreased safety awareness, and increased confusion. Resident #31 was a female readmitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction and epilepsy; her quarterly MDS showed her BIMS score could not be obtained and that she was dependent for ADLs. Resident #106 was a female admitted to the facility with diagnoses including unspecified dementia, anxiety, and major depressive disorder; her quarterly MDS also showed her BIMS score could not be obtained and that she was dependent for ADLs. Interviews confirmed the issue. Resident #106 stated she was not aware that housekeeping and other staff were required to knock before entering and said she would like staff to knock first so she is not surprised. Resident #31 stated staff did not always knock and that she should be knocked on before entry, adding that she is sometimes surprised by an unannounced visit. HK G stated she did not know why she forgot to knock and acknowledged residents could feel like they are not given privacy if staff do not knock. CNA H stated she had been trained on resident rights and that all staff were to knock before entering a resident's room, but said she did not realize she had not knocked because she was probably in a rush. The DON and ADM both stated that knocking before entering is part of resident rights and is required to protect privacy and respect.
Improper Portioning of Pureed Diet Menus
Penalty
Summary
The facility failed to follow the cycle menu for 3 residents on a pureed diet by using scoop sizes that did not match the menu directions. During breakfast and lunch observations on 4/21/2026, 4/22/2026, and 4/23/2026, CK F served pureed foods with a blue #16 scoop, a yellow #20 scoop, and a green #12 scoop for items that the menu specified should be served with larger scoops, including #8, #6, and #10 scoops depending on the item. The posted kitchen chart identified the scoop capacities and colors, and the diet spreadsheet was referenced by the DS as the guide for staff. Resident #2 was a [AGE]-year-old female with diagnoses including cerebral infarction, atrial fibrillation, dysphagia, pneumonitis due to inhalation of food and vomit, muscle wasting and atrophy, cognitive communication deficit, gastrostomy status, and need for assistance with personal care. Her care plan identified nutritional problems related to dysphagia and protein calorie malnutrition, and her physician ordered a pureed diet. Her weight record showed 145.9 pounds on 3/22/2026 and 135.4 pounds on 4/22/2026. Resident #23 was a [AGE]-year-old male with Parkinson's disease, unspecified dementia, muscle wasting and atrophy, dysphagia, cognitive communication deficit, and need for assistance with personal care. His care plan identified a potential nutritional problem related to dysphagia and newly diagnosed aspiration pneumonia, and he was ordered a pureed diet. His weight record showed 133.9 pounds on 4/22/2026 and 134.8 pounds on 2/25/2026. Resident #88 was a [AGE]-year-old female with psychotic disturbance, diverticulitis, dementia, muscle wasting and atrophy, dysphagia, cognitive communication deficit, anorexia, and need for assistance with personal care. Her MDS reflected a BIMS score of 15, and her physician ordered a pureed diet. Her weight record showed 124 pounds on 4/08/2026 and 126 pounds on 3/09/2026. The DS stated staff were taught how to read the scoop numbers and colors and that she monitored staff daily. The DON stated kitchen staff should follow the menu, and the ADM stated the facility had recently changed dietary companies and the menu sizes were slightly different on the new menu.
Call Lights Left Out of Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that a working call system was available and within reach for four residents who were reviewed for the ability to call for staff assistance. During observation and interview, Resident #41 was lying in bed with the call light wrapped around the right bed frame and out of reach, and the resident stated she could not reach it. Resident #31 was observed lying in bed with the call light on the floor and out of reach, and stated she could not reach it. Resident #42 was observed lying in bed with the call light wrapped around the left bedframe and out of reach, and stated she could not reach the call light button. Resident #76 was observed lying in bed with the call light hanging off the left side of the bed and out of reach; she could not be interviewed. Review of records showed Resident #41 had osteoarthritis, carpal tunnel syndrome, and age-related cognitive decline, with a BIMS score of 15 and a care plan directing staff to keep the call light within reach. Resident #31 had hemiplegia and hemiparesis following cerebral infarction, epilepsy, and cognitive communication deficit, with a care plan indicating she required assistance or supervision for ADLs. Resident #42 had dementia, a history of transient ischemic attack, depression, and cognitive communication deficit, and her care plan addressed impaired cognitive function. Resident #76 had hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and Parkinson's disease, and her care plan addressed impaired cognitive function. Interviews with CNA H, MA E, the DON, and the ADM confirmed that staff were responsible for placing call lights within residents' reach and that call lights should never be on the floor or otherwise out of reach. The facility policy stated the call device should be within the resident's reach before staff leave the room and that staff should provide a means of communication with nursing staff.
Failure to Provide Incontinent Care After Getting Resident Up
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for toileting hygiene, bed mobility, and transfers received incontinent care after being assisted out of bed. Resident #79 was a [AGE]-year-old female admitted with diagnoses including respiratory failure, heart failure, chronic skin loss with muscle involvement, resistance to multiple antimicrobial drugs, reduced mobility, morbid obesity with alveolar hypoventilation, muscle weakness, and irritable bowel syndrome. Her quarterly MDS reflected a BIMS score of 15 and indicated she did not reject care. Her care plan identified a potential for pressure ulcer development related to incontinence and included interventions related to skin breakdown prevention. During interview, the resident stated staff typically got her up around 10:30 a.m. and would not provide incontinent care until she laid back down, which was usually not until the 2-10 shift. She said there were times she asked to be changed and was told she had to wait for the next shift. CNA D stated he changed residents every two hours and got Resident #79 up around 10:30 or 11:00 a.m., but once she was in her wheelchair he did not change her again for the rest of his shift. He said he did not know what time the second shift would change her and did not ask her if she needed to be changed. He also stated that because she was moving around the facility or in an activity, she would have to wait until the next shift to get changed. The DON stated the resident preferred to get up around 11:00 a.m. and that she would inform the nurse when the resident was getting up so the nurse could watch incontinent care. The DON, CNA D, and the ADM all stated staff were responsible for providing incontinent care and checking residents every two to three hours or more often if needed. Observations showed the resident received incontinent care when she was transferred out of bed at 11:11 a.m. and again when she returned to bed at 2:21 p.m. The facility policy stated residents should receive the necessary care and services, including assistance with personal hygiene, grooming, dressing, toileting, transferring, ambulating, and eating.
Delayed Podiatry Care and Overgrown Toenails
Penalty
Summary
The facility failed to ensure that one resident received proper foot care and podiatry services to maintain mobility and good foot health. Resident #67 was admitted with multiple diagnoses including acute and chronic respiratory failure, morbid obesity, osteoarthritis, hypertensive heart and chronic kidney disease with heart failure, obstructive sleep apnea, gout, difficulty walking, unsteadiness on feet, cognitive communication deficit, and need for assistance with personal care. His MDS reflected a BIMS score of 15, and his care plan identified potential for skin breakdown with interventions including daily body checks and weekly head-to-toe assessments. A physician order dated 3/20/2026 allowed consultation with podiatry, and a progress note dated 3/23/2026 documented very long toenails. During interviews and observations, Resident #67 stated he had not seen a podiatrist and reported foot pain rated 10 out of 10. On observation, his toenails extended at least one inch past the nailbed. He also stated he had not been doing physical therapy due to foot pain and said he did not know whether trimming his nails would help. Staff interviews showed the referral process was delayed by insurance issues. The SW stated the resident had been referred to podiatry on admission, but insurance authorization was a problem and the resident had not seen the podiatrist since admission. LVN A stated the nails were too thick to cut and that the resident was likely on a waiting list. The NP stated she had requested podiatry because the nails were very bad, and the Podiatrist later found the toenails were extremely long and thick with onychomycosis, with one toe curled over and indenting the skin. The DON and ADM acknowledged the nails were excessively long and that the resident had not received timely podiatry care because of the insurance issue.
Medication Left Unsupervised With Residents
Penalty
Summary
The facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs and biologicals, for 2 of 10 residents reviewed for medication administration. Resident #51, an [AGE]-year-old female with dementia, muscle weakness, age-related cognitive decline, unsteadiness on feet, dysphagia, muscle wasting, and need for assistance with personal care, had a BIMS score of 11 and no Medication Self-Administer Assessment or care plan support for self-administration. During observation, she was eating breakfast with a cup containing three white pills and one brown pill left on her bedside table, and she stated the nurse left the medication so she could take it with breakfast. Resident #88, an [AGE]-year-old female with dementia, muscle weakness, unsteadiness on feet, dysphagia, muscle wasting, respiratory failure, hearing loss, and need for assistance with personal care, had a BIMS score of 15 and also had no Medication Self-Administer Assessment or care plan support for self-administration. During observation, her Albuterol HFA inhaler was left on her bedside table, and she stated staff had left it with her. She said staff normally did not leave medication with her. Staff interviews confirmed that medication was not to be left with residents and that staff were supposed to remain with the resident until the medication was swallowed. MA E stated she was trained that staff must watch residents take their medication and that she did not have any residents who could self-administer. The DON and ADM also stated residents were not to be left with medication, that no residents had completed self-administration assessments, and that the inhaler had been left behind when the overnight nurse forgot to retrieve it.
Failure to Protect Resident from Physical Abuse During Care
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident from physical abuse during personal care. The resident, an elderly female with severe cognitive impairment due to dementia and multiple comorbidities, was dependent on staff for all activities of daily living. On the morning in question, two CNAs entered the resident's room to change her brief. The resident expressed a desire to sleep and refused care, but the CNAs proceeded. According to the resident and her roommate, one CNA forcefully grabbed the resident's right hand and pulled her thumb backward, causing the resident to scream in pain. The roommate, separated by a curtain, heard the incident but could not see it. Video and audio evidence captured the resident shouting and screaming during the care episode, with the curtain drawn to block the camera's view. Following the incident, the resident was observed to have swelling and bruising on her right thumb, which was later diagnosed at the hospital as a comminuted, mildly displaced fracture of the base of the right first digital proximal phalanx with extension to the first digit joint. Staff statements indicated that the injury was not immediately reported, and the CNAs involved did not provide a clear account of how the injury occurred. The facility's records showed that the injury was only discovered when the resident was unable to use her hand to hold her phone, and subsequent assessment confirmed the injury. The facility's abuse policy required immediate reporting of suspected abuse or injuries of unknown origin, but this protocol was not followed in this case. Interviews with other staff and residents indicated that the incident was isolated, with no other reports of abuse or injury by staff. However, the failure to protect the resident from physical harm during care, the lack of immediate reporting, and the attempt to obscure the incident from video surveillance by drawing the curtain contributed to the deficiency. The event was determined to be an Immediate Jeopardy situation due to the serious injury and the failure to ensure the resident's right to be free from abuse.
Failure to Prevent and Report Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to develop and implement written policies and procedures that effectively prohibited and prevented abuse, neglect, and exploitation of residents, as well as misappropriation of resident property. This deficiency was identified through the case of a female resident with severe cognitive impairment, dementia, and multiple comorbidities, who was dependent on staff for all activities of daily living. The resident's care plan noted a risk for physical behaviors related to dementia, with interventions to analyze triggers and document de-escalation strategies. Despite these documented needs, the facility did not have effective interventions or services in place to address her care, resulting in the resident sustaining a comminuted and mildly displaced fracture of the right thumb, with extension to the first digit joint. The incident occurred when two CNAs were providing care to the resident. According to interviews and video evidence, the CNAs pulled the privacy curtain around the resident's bed, blocking the view of the camera. Audio from the video captured the resident shouting "stop" and screaming in pain. After the care was completed, the resident was observed with a bruised and swollen right thumb, which was later confirmed by X-ray to be fractured. The resident and her roommate both reported that the injury occurred during morning care, with the roommate hearing the resident cry out in pain. The CNAs involved did not report the injury at the time, and there was no documentation or explanation provided for how the injury occurred. Further review revealed that the facility's abuse, neglect, and exploitation policy emphasized residents' rights to be free from abuse and to have personal privacy respected. However, the policy was not effectively implemented, as evidenced by the lack of timely reporting, inadequate documentation, and failure to protect the resident from harm during care. The incident was only discovered after the resident was unable to use her hand, prompting further assessment and eventual transfer to the hospital. The facility's failure to implement its own policies and procedures directly contributed to the resident's injury and the subsequent identification of an Immediate Jeopardy situation.
Failure to Timely Report Suspected Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin, were reported immediately, but no later than two hours after the allegation was made, as required. Specifically, a resident with severe cognitive impairment and multiple comorbidities, including dementia, hypertensive heart disease, and chronic kidney disease, was found to have a significant bruise and swelling to her right thumb of unknown origin. The injury was first noted during a change of condition skin assessment, and there was no documentation indicating how the injury occurred. Interviews and record reviews revealed that the resident was dependent on staff for all self-care and mobility, requiring a wheelchair and comprehensive assistance. On the morning of the incident, the resident reported that two CNAs entered her room, and one of them pulled her thumb backward, causing her to scream in pain. A roommate corroborated hearing the resident cry out, though the curtain was drawn, preventing visual confirmation. The injury was later observed by another CNA, who reported it to a nurse, and the resident was subsequently transferred to a hospital for further evaluation. Despite the severity and unknown origin of the injury, the facility did not report the incident to the appropriate state authorities within the required timeframe. The incident was reported to Texas Health and Human Services via email more than 24 hours after the injury was first identified. The facility's own policy requires immediate reporting of suspected abuse, neglect, or mistreatment, but this protocol was not followed in this case.
Resident Identification Failure Leads to Missed Medical Appointment
Penalty
Summary
The facility failed to ensure accurate resident identification prior to transporting a resident for an outside medical appointment, resulting in the wrong resident being sent to a scheduled surgical appointment. Specifically, a resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, heart failure, and moderate recurrent major depressive disorder, who also had moderate cognitive impairment, did not attend his scheduled cataract surgery. Instead, another resident was mistakenly transported in his place. The error occurred when the driver, who had only been in the role for a few weeks, relied on a CNA's verbal confirmation rather than verifying the resident's identity using the face sheet or checking with the floor nurse as required by facility protocol. Interviews revealed that the driver did not follow the established process of bringing the face sheet to the resident's room and confirming the resident's identity through the electronic health record (PCC) and with nursing staff. The driver admitted to not reviewing the face sheet and instead asked a CNA in the hallway to identify the resident, leading to the mix-up. The facility did not have a written policy outlining the steps for verifying resident identity before transport to outside appointments, contributing to the deficiency.
Failure to Maintain Effective Pest Control Program Resulting in Ant Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of ants in one of the resident bedrooms. Observations confirmed the presence of ants in the room of a male resident with Parkinson's Disease, Chronic Kidney Disease, and muscle weakness. The resident reported that ants had been present for several weeks, crawling from the door frame, and that he experienced sharp sensations on his body after touching the ants, which he believed were bites. The resident stated that the facility was aware of the ant issue, had pest control services spray the area, but the problem persisted and continued to cause him discomfort and itching. The resident also indicated that his room was the only area affected by the ants. Interviews with facility staff, including the MD, DON, and ADM, revealed that pest control services were scheduled to visit the facility twice a month, with additional visits as needed. Staff were trained to report pest sightings, which were to be logged and communicated to the MD, who was responsible for pest control oversight. Despite these procedures, the ant infestation in the resident's room was not effectively resolved, and the resident required medical attention for suspected insect bites. Review of facility policy confirmed the expectation to report and address pest sightings, but the ongoing presence of ants indicated a failure in the implementation of the pest control program.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to ensure that a resident's representative was provided access to and copies of the resident's medical records as requested. The representative initially requested the records in February, and after being asked to complete an Authorization for Release of Information, returned the completed form in early March. The Health Information Manager (HIM) forwarded the request to the facility's legal team, which approved the release of the records. However, due to a breakdown in communication, the HIM was not included in the legal team's email response approving the release, and as a result, the records were not sent to the resident's representative. Interviews with facility staff, including the HIM, Social Worker (SW), Director of Nursing (DON), and Administrator (ADM), revealed confusion regarding the status of the request and a lack of follow-up to ensure the records were provided. The facility's policies did not specify procedures or time frames for processing medical record requests, nor did they clearly state the resident's right to receive copies of medical records. The resident involved had severe cognitive impairment and was at risk for impaired cognitive function, making timely access to records by the representative particularly important.
Failure to Ensure Dignified Meal Service for Residents
Penalty
Summary
The facility failed to uphold the dignity and quality of life for three residents by not ensuring timely and appropriate meal service. Resident #20, who has severe cognitive impairment and is dependent on staff for eating due to conditions such as cerebral palsy and dysphagia, was left with a meal tray placed in front of him without immediate assistance. This occurred despite the resident's care plan indicating the need for staff assistance with feeding, posing a risk of choking or other harm. Additionally, the facility did not ensure that Resident #49 and Resident #51 received their meals simultaneously with their tablemates. Resident #49, who has severe cognitive impairment and requires supervision for eating, and Resident #51, who also has severe cognitive impairment and needs setup assistance, experienced delays in receiving their meal trays compared to their tablemate. This inconsistency in meal service could lead to feelings of neglect or exclusion among residents. Interviews with staff, including a CNA, MA, the ADM, and the DON, revealed that they were aware of the facility's policy requiring all residents at a table to be served simultaneously and that residents needing assistance should not be left unattended with their meal trays. Despite this knowledge, the staff failed to adhere to these policies, resulting in the observed deficiencies. The facility's policies on meal service and resident rights emphasize the importance of treating residents with respect and dignity, which was not upheld in these instances.
Neglect in ADL Care for Residents
Penalty
Summary
The facility failed to provide necessary services for activities of daily living (ADLs) to several residents, specifically in maintaining good nutrition, grooming, and personal and oral hygiene. This deficiency was observed in four residents who were unable to carry out these activities independently. The facility did not ensure that the fingernails of these residents were trimmed over a period of several days, which could lead to hygiene issues and potential health risks. Resident #64, a male with Parkinson's Disease and chronic kidney disease, had untrimmed fingernails for four months. Despite his cognitive impairment and need for assistance with personal care, his nails were not maintained as per his care plan. Similarly, Resident #42, a female with Type 2 diabetes and dementia, had long and dirty fingernails, with one nail detached from the nailbed. She was completely dependent on caregivers for personal hygiene, yet her nail care needs were neglected. Additionally, Resident #31 and Resident #104 also had untrimmed nails, with no documented nail care in the last 30 days. Resident #28 was observed with a strong urine odor, indicating a lack of proper incontinent care and ADL assistance. Interviews with staff revealed inconsistencies in the provision of nail care and toileting assistance, highlighting a systemic issue in meeting the residents' ADL needs.
Inadequate Access to Call Light System for Residents
Penalty
Summary
The facility failed to ensure that each resident's bedside, toilet, and bathing facilities were adequately equipped with a working call system, which would allow residents to call for staff assistance. This deficiency was observed in the cases of two residents. Resident #102, a male with multiple health issues including congestive heart failure, chronic kidney disease, and a recent right femur fracture, was found to have his call light wrapped around the bedrail on the left side of his bed, making it out of reach. Despite his care plan indicating the need for the call light to be within reach due to his high risk for falls, this was not adhered to, potentially compromising his safety and ability to call for assistance. Another resident, Resident #34, also experienced similar issues with the call light system. This resident, who has contractures of the right hand and limited range of motion in the left hand, reported that her call light was frequently placed out of reach by staff. Observations confirmed that the call light was dangling and looped around the handrail, making it inaccessible to her. This situation could prevent her from receiving timely assistance, especially given her physical limitations. Interviews with various staff members, including the Director of Nursing (DON), Social Worker (SW), and Certified Nursing Assistants (CNAs), revealed a consensus that residents should always have access to their call lights. Staff acknowledged that not having access to call lights could negatively affect residents physically, mentally, and psychologically. Despite the facility's policy requiring call lights to be within reach, the observations and interviews indicated a failure to consistently implement this policy, thereby placing residents at risk of unmet needs and potential harm.
Inadequate Infection Control and PPE Use in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper incontinent care and lack of adherence to Enhanced Barrier Precautions (EBP) for two residents. Resident #1, a female with severe cognitive impairment and total dependence on staff for toileting hygiene, was observed receiving inadequate perineal care from CNAs B and C. Both CNAs used the same wipes multiple times without folding or changing them, and failed to clean the resident's groin and vaginal areas properly, which could lead to infection. Resident #2, also with severe cognitive impairment and requiring total assistance for incontinent care, was not provided with the necessary PPE during high-contact care activities. CNA D did not perform hand hygiene appropriately, failed to wear a gown, and used the same wipes multiple times during perineal care. Additionally, there was no signage or PPE bin at Resident #2's door to indicate the need for EBP, despite the resident having a foley catheter and a sacral wound, which required enhanced precautions. Interviews with staff revealed a lack of awareness and adherence to infection control protocols. CNA D admitted to not having sanitizer available and not following proper wiping techniques due to the resident's condition. The Central Supply staff and the Director of Nursing acknowledged the absence of necessary signage and PPE, which are critical for preventing infection transmission. The facility's policies on infection prevention, hand hygiene, and peri care were not followed, contributing to the deficiency.
Improper Mechanical Lift Transfer by Single CNA
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident who required assistance with transfers. The resident, who had severe cognitive impairment and was totally dependent on staff for transfers, was transferred by a CNA using a mechanical lift without the required assistance of a second staff member. This action was contrary to the resident's care plan, which specified the need for two staff members during mechanical lift transfers to ensure safety. The incident was captured on a closed-circuit video, showing the CNA performing the transfer alone, without any observed impacts or distress from the resident. However, this action placed the resident at risk of injury, as the facility's policy and staff training emphasized the necessity of two-person assistance for mechanical lift transfers. The deficiency was identified following a report from the resident's family, highlighting the failure to adhere to established safety protocols.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's physical status. Specifically, the facility did not inform the nurse practitioner (NP) of a resident who began consistently refusing and/or spitting out her medications starting in mid-December 2024. This resident, a female with severe cognitive impairment and a history of dysphagia, was admitted with diagnoses including essential hypertension, type II diabetes, and dementia. Despite the resident's medication administration records indicating multiple instances of refusal and spitting out medications, the NP was not informed of these occurrences, which is a requirement according to the facility's policy. Interviews with facility staff revealed that both LVN A and LVN B were aware of the resident's behavior but did not ensure the NP was notified. LVN A believed the NP was aware, while LVN B could not recall if she had informed the NP. The Director of Nursing (DON) confirmed that the NP should have been notified of multiple medication refusals to discuss and determine necessary actions. The facility's policies on physician notification and medication administration were not adhered to, leading to a deficiency in resident care.
Infection Control Deficiencies During Peri Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during peri care for two residents. CNA A did not wash or sanitize her hands before donning gloves and handled a wet wipe packet with soiled gloves, contaminating it. She also failed to sanitize the wheelchair surface after placing shoes on it and did not wash or sanitize her hands after completing peri care. These actions were observed during care for a male resident with multiple diagnoses, including cognitive impairment and incontinence. Similarly, CNA B did not sanitize her hands before donning gloves and contaminated a wet wipe packet by handling it with soiled gloves. She also left the room without washing or sanitizing her hands, leading to contamination of various items, including a new brief and bed linens. This occurred during care for a female resident with severe cognitive impairment and a need for extensive assistance with activities of daily living. Both CNAs acknowledged their failure to follow infection control protocols during interviews, citing nervousness and forgetfulness. The Director of Nursing stated that staff are expected to sanitize hands and equipment appropriately to prevent the spread of infections. The facility's hand hygiene policy emphasizes the importance of handwashing and the use of alcohol-based hand rubs to prevent healthcare-associated infections.
Inaccessible Call Buttons for Residents
Penalty
Summary
The facility failed to ensure that call buttons were within reach for three residents, which compromised their ability to request assistance and have their needs met. Resident #2, a female with severe cognitive impairment and hemiplegia, was found in her wheelchair with her call button on the floor, out of her reach. She expressed that she was not feeling well and would have used the call button to call for help if she had known its location. The TXN acknowledged the oversight during her rounds. Resident #3, a female with intact cognition but requiring assistance for ADLs, had her call button cord wrapped around her mattress and under the fitted sheet, making it inaccessible. She was unaware of its location and mentioned that she would go to the nurse's station if she needed help. The TXN discovered the call button under the mattress and noted that CNAs were responsible for making the beds. Resident #4, a male with moderate cognitive impairment and hemiplegia, had his call button cord on the floor on the opposite side of his bed, out of his view and reach. He indicated that he usually looked for the call button next to his bed. CNA C, who made the beds for these residents, stated she always ensured call buttons were in place but was unsure how they became inaccessible. The DON confirmed that call buttons should always be within reach and acknowledged the potential impact of this deficiency.
Failure to Ensure Safe Transfer Procedures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident who required assistance with transfers. The resident, who had severe cognitive impairment and was totally dependent on staff for transfers, was transferred by a CNA using a mechanical lift without the required assistance of a second staff member on two separate occasions. The care plan for the resident specified that transfers required two staff members using a hoyer lift, yet the CNA conducted the transfers alone, contrary to the facility's policy and training. Interviews with staff, including the CNA involved, the SC, ADON, and DON, confirmed that mechanical lift transfers always required two staff members for safety reasons. The facility had previously conducted training and performance reviews to ensure staff were aware of the proper procedures for mechanical lift transfers, emphasizing the need for two staff members. Despite this, the CNA denied conducting the transfers alone, although video evidence showed otherwise. The facility's policy and staff training were not adhered to, placing the resident at risk of injury.
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 342 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sedona Trace Health And Wellness Center | 2.3 mi | ★★★★★ | 3 | 0 |
| Gracy Woods Ii Living Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Gracy Woods Nursing Center | 3 mi | — | 21 | 1 |
| Avir At Park Bend | 3.4 mi | ★★★★★ | 8 | 0 |
| Oakcrest Nursing And Rehabilitation Center | 4 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Legend Oaks Healthcare And Rehabilitation - North.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.