Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legend Oaks Healthcare And Rehabilitation - West S during CMS and state inspections, most recent first.
A resident with BPH, neurogenic bladder, and an indwelling urinary catheter received improper catheter care when a CNA grasped the resident’s genitals instead of the catheter tubing and wiped along the tubing in a way that made it taut, repeating this several times. The resident, who had moderately impaired cognition, did not voice pain during the procedure. Facility policy and staff training required grasping and securing the catheter tubing and cleaning downward from the meatus to prevent migration, friction, or tension, and competency records showed the CNA had been validated in this skill.
A resident with a suprapubic catheter and moderately impaired cognition was care-planned for Enhanced Barrier Precautions (EBP), with signage on the door and facility policy requiring gown and gloves for high-contact care. During observed incontinence care, a CNA applied a disposable brief without wearing a gown, despite having received infection prevention training. In interviews, the CNA acknowledged she should have worn a gown and the ADON/Infection Preventionist confirmed that gowns and gloves were required for close-contact care under EBP, indicating the facility did not follow its own IPCP and EBP policy.
Inaccurate MDS documentation of insulin use affected three residents with diabetes-related diagnoses. For one resident, the MDS recorded insulin injections that did not match the MAR; for a second resident, the MDS also overstated insulin use compared with the MAR; and for a third resident, the MDS recorded insulin injections even though the MAR showed none during the look-back period. The MDS Nurse stated assessments should be checked for accuracy before submission to the DON, and the DON stated the MDS must be accurate because it is used for billing and resident care information.
An insulin pen in a nurse med cart was not dated after removal from the fridge, loose pills were found in the cart, and a pill cutter had white residue on it. A resident also had Mentholatum ointment at the bedside without documentation of self-administration assessment, physician order, or care planning. Staff and the DON acknowledged the storage and handling concerns.
Food service safety standards were not followed in the kitchen and nourishment room. Unlabeled items were observed in the pantry and nourishment refrigerator, open food items were found in the freezer, and an aide was observed serving lunch with a hairnet not fully covering the hair. The dietary manager stated staff were responsible for labeling items and that hair nets were expected to cover all hair.
Infection Control Breaks During Catheter and Incontinent Care: Staff were observed handling catheter and incontinent care with breaks in hand hygiene, glove changes, and PPE use. A resident on EBP had a catheter bag touching the floor, a CNA handled the bag without a gown, and CNAs continued care after gloves became soiled with stool or after moving from a soiled bed pad to a clean brief. Another resident with an indwelling catheter was also observed with the drainage bag touching the floor.
Missing Discharge MDS and Transfer Documentation: A resident admitted with COPD was discharged home after respite care, but the facility did not document the transfer/discharge in the medical record with a discharge MDS. The EMR showed an admission MDS only, and the MDS nurse and DON both confirmed the discharge MDS should have been completed.
Pre-signed controlled drugs-count record: The facility failed to ensure controlled drug counts were documented correctly for the 300 hall nurse medication cart. An LVN was observed having already signed the off-going nurse section for the upcoming shift before the narcotic count occurred with the oncoming nurse. The LVN stated the signature should not have been entered until the end of the shift, and the DON stated staff were expected to sign only when relieved and after counting narcotics with the other nurse.
A CNA failed to perform hand hygiene and change gloves between cleaning a resident's vaginal and rectal areas during incontinence care, resulting in a break in infection control procedures. The resident had significant cognitive and physical impairments and required frequent assistance with incontinence care. Facility policy and the CNA's training required proper hand hygiene and glove changes, but these were not followed during the observed care.
The facility did not distribute mail received on Saturdays to residents, leading to a delay in mail delivery. Residents expressed dissatisfaction with this practice, which was confirmed by interviews with staff, including the ADON and Weekend Receptionist. The facility's policy indicated mail should be delivered on the day of receipt or the next business day.
A resident with heart failure, type II diabetes, and dementia was provided a personal locked box for his money, but the facility failed to update his care plan to reflect this. The MDS nurse was unaware of the locked box, leading to a lack of communication in the care plan. The DON acknowledged the oversight, which could result in staff providing incorrect care.
The facility failed to ensure adequate supervision for two residents with a history of suicidal ideations and Major Depression. One resident attempted suicide by ingesting mouthwash, while another had potentially harmful items in her room. Staff were not aware of the residents' suicidal histories, leading to a lack of proper monitoring and supervision.
A resident with a history of major depression and suicidal ideation attempted suicide by ingesting mouthwash. The incident was discovered by a CNA and reported to the RN, who notified the MD, NP, family member, EMS, and law enforcement. Despite the severity of the incident, the facility did not report it to the Health and Human Services Commission (HHSC) within the mandated two-hour window, as required by their policies and state regulations.
Improper Catheter Care Technique Resulting in Tension on Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate catheter care for a resident who was incontinent of bladder and had an indwelling urinary catheter. The resident was an elderly male with benign prostatic hyperplasia and neurogenic bladder, with a moderately impaired cognitive status (BIMS score of 09), and had an indwelling catheter in place per his MDS and care plan. Facility policy on indwelling urinary catheter care directed staff to clean the catheter in a downward motion from the urinary meatus toward the collection bag and to secure the tubing as needed to prevent migration, friction, or tension. During an observed episode of routine catheter care, CNA A grasped the base of the resident’s genitals instead of the catheter tubing and wiped along the catheter tubing away from the resident’s body, causing the catheter tubing to become taut. She repeated this action three times. The resident did not express pain or discomfort and stated he was okay. In subsequent interviews, CNA A and the ADON both stated that staff were trained to grasp the catheter tubing before wiping, and both identified that not securing the tube while cleaning could lead to accidental removal, trauma to the catheter site, or displacement. The facility’s competency checklist documented that CNA A had been validated as competent in male perineal care with a catheter, indicating that the observed technique did not follow her training or facility policy regarding prevention of catheter tension.
Failure to Follow Enhanced Barrier Precautions During Care of Catheterized Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) for a resident with an indwelling suprapubic catheter. The resident was an older male with benign prostatic hyperplasia and lower urinary tract symptoms, admitted with a diagnosis requiring an indwelling catheter, and had a BIMS score of 07 indicating moderately impaired cognition. The resident’s MDS documented the presence of an indwelling catheter, and the care plan reflected that the resident had a suprapubic catheter and was to be cared for under EBP beginning on 9/17/2025. A sign on the resident’s exterior door indicated that EBP were in place. During an observation, a CNA was seen applying a clean disposable brief to this resident without wearing a disposable gown, despite the resident being on EBP. The CNA later stated in an interview that she had received infection prevention training, acknowledged she should have worn a disposable gown while applying the brief, and attributed the lapse to being nervous, noting the potential risk was infection. The ADON, who served as the facility’s Infection Preventionist, confirmed in an interview that staff were required to wear disposable gowns and gloves during close-contact care for residents on EBP and that the CNA should have worn a gown during this care activity. The facility’s written policy on IPCP Standard and Transmission-Based Precautions, revised in 3/2024, specified that EBP expand the use of PPE through the use of gown and gloves during high-contact resident care activities, which was not followed in this instance.
Inaccurate MDS Documentation of Insulin Use
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected insulin use for 3 of 6 residents reviewed. Resident #17 had diagnoses including type 2 diabetes mellitus, dementia, schizoaffective disorder, depression, hypertension, and cerebral ischemia. Her quarterly MDS documented an answer of 7 for Section N0350 insulin injections, but the MAR showed Humalog insulin was actually administered on 4 days during the 7-day look-back period. Her care plan also identified diabetes and included medication monitoring interventions. Resident #78 had diagnoses including kidney disease, cerebral infarction, hypertension, hyperlipidemia, heart disease, and peripheral vascular disease. Her quarterly MDS also documented an answer of 7 for insulin injections, while the MAR showed NovoLog insulin was administered on 4 days during the 7-day look-back period. Her care plan identified diabetes and included interventions for administering NovoLog and monitoring and reporting signs and symptoms of hypoglycemia and hyperglycemia. Resident #108 had diagnoses including type 2 diabetes mellitus, cerebral infarction, dementia, hyperlipidemia, hypertension, and heart disease. Her MDS documented an answer of 7 for insulin injections, but the MAR showed no insulin injections were given during the 7-day look-back period. Her care plan identified diabetes-related risks and included medication and monitoring interventions. The MDS Nurse stated the assessment should be checked for accuracy before submission to the DON, and the DON stated the MDS should be accurate because it is used for billing and because inaccurate data could have negative outcomes for a resident.
Medication Storage and Resident Bedside Medication Issues
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles for the 300-hall nurse medication cart, the 200/300 hall medication cart, and one resident’s room. During observation and interview, an insulin pen was removed from the 300-hall cart and the LVN stated he was going to date it, then said it had not been used and did not need to be dated. The LVN then returned the pen to the drawer. In the same cart, four loose pills were found under residents’ blister packs, and the LVN stated he did not know what they were and that loose pills should not be in the cart because their source and expiration status were unknown. In the 200/300 hall medication cart, a pill cutter was observed with a white residue on the blade and cutting surface. The MA stated she had not used it and said it could not be dirty because it could cause cross contamination. The DON later stated the loose pills should have been discarded, insulin pens should be dated once removed from the fridge to ensure they are used by the manufacturer’s date or discarded after, and the pill cutter should be cleaned or cross contamination could occur. Resident #148, a female admitted after joint replacement surgery with migraines and hypertension, had a BIMS score of 14 out of 15. During observation, a container of Mentholatum ointment was on her bedside table, and the resident stated she used it for her nose when congested and had brought it from home. Staff interviews reflected that residents should not have medication in their rooms unless a self-administration assessment, physician order, and care plan were completed. The DON stated residents can have medication in their possession only if those steps are completed.
Food Storage and Hair Restraint Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. During observation on 01/26/2026 at 12:30 p.m., the kitchen pantry contained 16 loaves of bread, 1 box of clear fry oil, 1 Ziploc bag of relish packets, 1 Ziploc bag of salt packets, and 1 Ziploc bag of individual packs of goldfish, all with no date. The kitchen freezer also contained 1 open bag of frozen sugar cookie dough and 1 open bag of French toast sticks. The dietary manager stated that anyone in the kitchen was responsible for labeling items and that food items not correctly sealed in the freezer could get freezer burn and have to be discarded. On 01/27/2026 at 10:20 a.m., the nourishment room refrigerator contained 1 Med Pass 2.0 fortified nutritional shake with no date. The dietary manager stated the kitchen was responsible for the nourishment room and that items without a date or label would be discarded. During lunch service on 01/27/2026 at 12:25 p.m., Dietary Aide F was observed serving lunch with the hairnet halfway up the back of the hair. The dietary manager stated the expectation was that hair nets cover all kitchen staff hair, and Dietary Aide F stated they had been trained on proper hairnet use and that the hair net should cover all hair. The DON stated on 01/29/2026 that they were not aware of any food borne illness outbreaks in 2025.
Infection Control Breaks During Catheter and Incontinent Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for residents with indwelling urinary catheters and during incontinent care. Resident #96, who had diagnoses including diabetes, respiratory failure, mild cognitive impairment, heart failure, and benign prostatic hyperplasia, had an indwelling urinary catheter and was on Enhanced Barrier Precautions. During observations, the resident’s catheter bag was seen touching the floor while the tubing drained urine into the bag. When CNA A later handled the catheter bag, she wore gloves but did not wear a gown, and stated she should have been wearing one when handling the bag. During catheter and incontinent care for Resident #96, CNA C was observed cleaning the resident’s anal area after stool was present on the gloves. The CNA continued care with gloves that had stool on them, dropped a soiled wipe onto the resident’s leg, and then removed the gloves without washing hands with soap and water, instead sanitizing her hands before putting on a new pair of gloves. The CNA then rolled up a bed pad that had stool on it and used the same gloves to place a clean incontinent brief on the resident. CNA C and CNA A stated the gloves should have been changed once soiled and that touching the soiled bed pad and then the clean brief with the same gloves was cross contamination. A similar break in infection control occurred during incontinent care for Resident #14, who had diagnoses including obstructive uropathy, diabetes, and benign prostatic hyperplasia and had an indwelling urinary catheter and bowel incontinence. CNA A cleaned the resident’s buttocks and anal area, removed gloves, sanitized hands, and put on a new pair of gloves. She then retrieved a clean incontinent brief, realized she had not removed the soiled bed pad, and after removing the soiled pad, used the same gloves to handle the clean brief and place it on the resident. Resident #108, who had diabetes, obstructive and reflux uropathy, muscle wasting, chronic kidney disease, an indwelling urinary catheter, and bowel incontinence, was also observed with the catheter bag touching the floor after the bed was lowered. CNA B stated the bag had been tied to keep it off the floor but was still touching the floor, and identified this as an infection control issue.
Missing Discharge MDS and Transfer Documentation
Penalty
Summary
The facility failed to ensure that Resident #123’s transfer or discharge was documented in the resident’s medical record, and a discharge MDS was not completed for the resident. Resident #123 was admitted on 08/26/2025 with a primary diagnosis of chronic obstructive pulmonary disease and was later documented as discharged home on 09/30/2025 at approximately 11:00 a.m. via a local transport company in a wheelchair after being on respite care from 09/25/2025 to 09/30/2025. Record review showed an admission MDS completed on 09/25/2025, but no discharge MDS was found in the EMR after the resident’s discharge. During interview, the MDS nurse stated discharge MDSs should be completed by the 14th day after discharge and confirmed that Resident #123 did not have one completed. The DON also stated that Resident #123 should have had a discharge MDS and that it shows the whole picture of the resident and may be needed for accuracy if submitted to another facility. The facility policy stated that MDS transmission includes resident transfer, entry, reentry, discharge, and death documents.
Pre-signed controlled drugs-count record
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 7 medication carts reviewed, involving the 300 hall nurse medication cart. During observation and record review on 1/29/26 at 8:46 a.m., LVN D was observed to have pre-signed the controlled drugs-count record for the 3:00 p.m. to 11:00 p.m. shift. The controlled drugs-count record for January 2026 contained LVN D's signature in the section designated for the off going nurse for that shift, even though the narcotic count had not yet occurred with the oncoming nurse at shift change at the time the signature was observed. During interview on 1/29/26 at 8:49 a.m., LVN D stated the controlled drugs-count record was used to know who counted the narcotics at the end or beginning of their shift and stated he should not have signed the document until the end of his shift when he counted all the narcotics with the oncoming nurse. During interview on 1/29/26 at 11:48 a.m., the DON stated staff were expected to sign the controlled drugs-count record when a nurse came in to relieve them and that they needed to count to make sure all narcotic medications were accounted for and none were missing. The facility policy titled Controlled Medications-Storage and Reconciliation stated that a reconciliation or physical inventory of all controlled medications is conducted by two licensed nurses and documented at each shift change.
Failure to Follow Hand Hygiene and Glove Change Protocol During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinent/peri care for a resident. The CNA washed her hands initially, but after using the bed remote, she donned gloves without performing hand hygiene. During the care, the CNA used the same pair of gloves to clean both the resident's vaginal area and then the rectal/buttock area, without changing gloves or performing hand hygiene between these tasks. The CNA acknowledged during an interview that she should have changed gloves and performed hand hygiene between these steps, recognizing this as a break in infection control and cross-contamination. The resident involved was a female with multiple diagnoses, including encephalopathy, memory deficit, Parkinson's disease, muscle wasting, lack of coordination, and urinary retention. She was moderately cognitively impaired, required substantial assistance with mobility, and was frequently incontinent of bladder and always incontinent of bowel. Facility policy and the CNA's competency checklist both required proper hand hygiene and glove changes during incontinence care, but these procedures were not followed during the observed incident.
Failure to Distribute Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents' right to receive mail in a timely manner, as mail received on Saturdays was not distributed to residents. During a confidential group meeting, residents expressed that they did not receive mail on Saturdays and felt this practice was disrespectful. Interviews with the Assistant Director of Nursing (ADON), Assistant Business Office Manager (ABOM), and Weekend Receptionist revealed that mail was left for sorting and distribution on Mondays unless residents specifically requested their mail. The Director of Nursing (DON) acknowledged that residents should receive their mail on Saturdays. The facility's undated policy stated that the business office would deliver mail to residents' rooms on the day of delivery or the next business day.
Failure to Update Resident Care Plan for Personal Lock Box
Penalty
Summary
The facility failed to review and revise the care plan for a resident, identified as Resident #28, after a comprehensive assessment. Resident #28, a 65-year-old male with diagnoses including heart failure, type II diabetes, and unspecified dementia, was admitted to the facility with an intact cognitive status as indicated by a BIMS score of 15. Despite being provided with a personal locked box for his money, this information was not updated in his care plan. The MDS nurse admitted to not being aware of the locked box and therefore did not update the care plan accordingly. The Director of Nursing (DON) confirmed that the MDS nurse should have updated the care plan following the quarterly MDS assessment, as the resident had received the locked box prior to this assessment. The failure to update the care plan could lead to staff being unaware of the resident's use of a personal lock box, potentially resulting in incorrect care. The facility's policy requires the interdisciplinary team to develop a comprehensive, person-centered care plan for each resident, which includes measurable objectives and time frames.
Inadequate Supervision for Residents with Suicidal Ideations
Penalty
Summary
The facility failed to ensure adequate supervision for two residents with a history of suicidal ideations and Major Depression. Resident #1, who had a history of suicidal ideations and a diagnosis of Major Depression, attempted suicide by ingesting mouthwash. The resident was found slumped over in his wheelchair and was subsequently sent to the ER and placed under emergency detention. The facility did not have adequate measures in place to monitor items brought into the resident's room, and staff were not aware of the resident's suicidal history, leading to a lack of proper supervision and monitoring for harmful items. Resident #2, also diagnosed with Major Depression, had items in her room that could pose a danger of self-harm, including a mouthwash bottle and shampoo bottles. The resident expressed feelings of sadness and occasional thoughts of self-harm, but there was no plan in place to monitor or remove potentially harmful items from her room. The facility staff, including CNAs and nurses, were not aware of the resident's suicidal ideation history and did not conduct regular checks for harmful items. The facility's failure to implement adequate supervision and monitoring for residents with a history of suicidal ideations and Major Depression resulted in an Immediate Jeopardy situation. The facility did not have a policy in place to inventory items brought in from the outside for residents at risk of self-harm, and staff were not adequately trained to identify and remove potentially harmful items. This lack of supervision and monitoring could lead to injury, harm, or death for residents with suicidal tendencies.
Failure to Report Suicide Attempt
Penalty
Summary
The facility failed to report an allegation of a suicide attempt by a resident to the State Survey Agency within the required timeframe. On 03/21/24, a resident with a history of suicidal ideation and depression attempted suicide by ingesting mouthwash. The incident was discovered by a CNA and reported to the RN, who then notified the MD, NP, family member, EMS, and law enforcement. Despite the severity of the incident, the facility did not report it to the Health and Human Services Commission (HHSC) within the mandated two-hour window for serious bodily injury or abuse allegations. The resident involved had a history of major depression and previous suicide attempts, including an incident where he tried to smother himself and lick deodorant. On the day of the incident, the resident was found shaking uncontrollably and admitted to attempting suicide by drinking mouthwash. EMS and law enforcement were called, and the resident was subsequently admitted to a psychiatric hospital. The facility's records and interviews with staff confirmed that the incident was not reported to HHSC as required by the facility's own policies and state regulations. Interviews with the Director of Nursing (DON) and the Administrator revealed that they did not believe the incident warranted reporting to HHSC, as they did not consider it neglect. The DON and Administrator cited a Provider Letter and concluded that the suicide attempt was due to family dynamics rather than neglect. This decision was made despite the facility's policies on abuse, neglect, and suicide threats, which mandate immediate reporting of such incidents to the appropriate authorities.
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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