Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Legacy Midtown Park during CMS and state inspections, most recent first.
A resident with COPD, acute diastolic HF, and acute respiratory failure had two albuterol inhalers on her nightstand even though she had no active order for albuterol or self-administration and no assessment for medication self-administration in her EHR. The resident said she kept one inhaler at bedside and another with her when leaving the room, while an LVN confirmed the inhalers were in the room and the DON stated the resident was not authorized to have medications in her room. The facility policy required medications and biologicals to be stored in locked compartments with access limited to authorized personnel.
A resident with COPD and respiratory failure was not provided oxygen at the physician-ordered rate of 4 LPM; instead, the oxygen concentrator was set at 1 LPM. Staff interviews revealed confusion about the correct flow rate, with a CNA referencing a different order and not verifying with a nurse, and an LVN confirming the incorrect setting. The facility's policy required verification of orders and correct administration, but this was not followed.
Two residents experienced unwitnessed falls resulting in hip fractures and were sent to the hospital, but the facility did not report these serious injuries to the State Survey Agency within the required timeframe. Staff determined that reporting was unnecessary because the residents could communicate that they had fallen, despite facility policy and regulations requiring immediate reporting of such incidents.
Incorrect Oxygen Flow Setting: A resident with pneumonia, COPD, and acute/chronic respiratory failure was ordered oxygen at 4 L/min via NC, but the concentrator was observed set at 1 LPM. Staff gave conflicting information about the correct flow rate, and an LPN later verified the incorrect setting while the resident remained in bed with the NC on and an O2 saturation of 95%.
The facility's kitchen failed to meet food safety standards, with unlabeled and expired food items found in storage. Molded fruit and other expired items were not discarded, posing a risk of food-borne illness. The Dietary Manager acknowledged these issues, which contravened the facility's food storage policy.
Unsecured Albuterol Inhalers Found in Resident Room
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and to limit access to authorized personnel when two albuterol inhalers were found on a resident’s nightstand. The resident was a cognitively intact female with diagnoses including acute diastolic heart failure, COPD, and acute respiratory failure. Her MDS reflected she was not receiving respiratory treatments or respiratory therapy, and her care plan included elevating the head of bed due to COPD and ARF and giving aerosol or bronchodilator medication as ordered. Record review showed the resident did not have an active physician’s order for albuterol, aerosols, bronchodilators, or self-administration of medications. Her EHR also did not contain an assessment to determine whether she could self-administer medications. Hospital discharge paperwork reflected she had received albuterol nebulizer treatments in the hospital, but there was no prior-to-admission order for albuterol. During observation, the resident stated she kept one inhaler at her bedside and another with her when she left the room, and she reported using them as needed for shortness of breath or wheezing. An LVN visually confirmed the two inhalers in the room and told the resident the medications would be taken and kept at the nursing station. He stated he did not know how long the inhalers had been there and said they should not have been in the room. The DON reported she was unaware the inhalers were in the resident’s room, stated the resident was not authorized to have medications in her room, and said the facility policy required a physician order for self-administration. The facility policy stated all medications and biologicals are to be stored in locked compartments and only authorized personnel may have access to the keys.
Failure to Administer Oxygen per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of pneumonia, acute and chronic respiratory failure with hypoxia, and COPD was not provided oxygen therapy according to the physician's order. The resident's care plan and physician's order specified oxygen administration at 4 liters per minute (LPM) via nasal cannula. However, on the date of observation, the oxygen concentrator was set at 1 LPM while the resident was in bed. The resident reported that staff had previously set the oxygen at 4 LPM. During interviews, a CNA stated she believed the oxygen should be set at 2 LPM, based on instructions for another resident, and admitted she had not checked with the nurse regarding the correct setting. The CNA also stated she was supposed to verify the setting with the nurse but had not done so. Further observation and interview with an LVN confirmed the concentrator was set at 1 LPM, and the LVN acknowledged the risk of hypoxia if the setting was incorrect. The LVN stated that both nurses and other staff involved in care were responsible for ensuring the correct oxygen setting. The DON and Administrator both confirmed that the nurse was responsible for following the physician's order and communicating the correct flow rate to the CNA. Facility policy required verification of physician orders and correct oxygen administration, but the observed practice did not align with these requirements.
Failure to Timely Report Serious Injuries from Unwitnessed Falls
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made, to the administrator and the State Survey Agency as required by regulation. Specifically, two residents who experienced unwitnessed falls resulting in serious injuries were not reported to the State Survey Agency. In both cases, the facility did not interpret the incidents as requiring immediate reporting, as the source of the injury was considered known due to the residents being found on the floor and able to communicate that they had fallen. One resident, an elderly male with multiple diagnoses including a prior right tibial fracture, muscle weakness, cognitive impairment, and a high risk for falls, was found on the floor of his room at night. He was assessed, transferred to bed, and later noted to have blood in his Foley catheter bag and pain in his right hip. He was subsequently sent to the hospital, where a fractured hip and blood loss were identified. Despite the unwitnessed nature of the fall and the serious injury, the incident was not reported to the State Survey Agency as required. A second resident, an elderly female with severe cognitive impairment, functional limitations, and a high fall risk, was found on the floor during CNA rounds, complaining of severe pain in her hip and leg. She had a skin tear and bruising, and EMS was called to transfer her to the hospital, where a fractured hip was diagnosed. The facility did not report this incident to the State Survey Agency, as staff believed the cause of the injury was known. Interviews with facility staff and review of facility policy confirmed that unwitnessed falls with serious injury were not reported if the resident could communicate that they had fallen, contrary to regulatory requirements.
Incorrect Oxygen Flow Setting
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for Resident #6 by not providing oxygen at the physician-ordered setting of 4 L/min via nasal cannula. Resident #6 was an [AGE]-year-old male admitted with pneumonia, acute and chronic respiratory failure with hypoxia, and COPD. His admission MDS showed a BIMS of 11, indicating moderate cognitive impairment. His care plan identified altered respiratory status/difficulty breathing related to COPD and acute respiratory failure, with interventions including oxygen via nasal cannula per physician orders and monitoring for signs and symptoms of respiratory distress. The active physician’s order summary directed oxygen at 4 L/min via nasal cannula every day and night shift, but on observation the oxygen concentrator in Resident #6’s room was set at 1 LPM. Resident #6 was lying in bed with the nasal cannula on and stated staff had been running it at 4 LPM. CNA B stated she believed the resident’s oxygen was supposed to be set at 2 LPM and said she had not checked with the nurse. LVN A later verified that the concentrator was set at 1 LPM, checked the order on the computer, and noted the resident’s oxygen saturation was 95%. The DON and Administrator stated that the licensed nurse was responsible for ensuring the oxygen setting matched the physician’s order and that CNAs were to verify the setting with the nurse.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. The survey revealed that food items in the refrigerator, freezer, and dry storage room were not labeled when removed from their original packaging. This included a variety of items such as corn tortillas, vacuum-sealed packages, cooked eggs, cottage cheese, lactose-free milk, blue cheese, strawberries, blueberries, carrots, roast beef, and unidentified meats. The lack of labeling could lead to confusion about the freshness and safety of these food items. Additionally, the facility did not discard expired food items stored in the refrigerator, freezer, or dry storage. The survey found food items that were past their expiration or best-used-by dates, ranging from three days to six months overdue. Molded fruit was also found in the refrigerator, which was not removed until it was pointed out by the surveyors. These practices could potentially expose residents to food-borne illnesses and cross-contamination. The Dietary Manager acknowledged the presence of expired and molded items during an interview and stated that such items are typically discarded. However, the survey findings indicated a failure to consistently implement this practice. The facility's Food Receiving and Storage Policy requires that all foods be labeled and dated, and that a first-in, first-out system be used, but these procedures were not followed as observed during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At The Meadow | 0.7 mi | ★★★★★ | 36 | 0 |
| Walnut Place | 0.7 mi | — | 0 | 0 |
| Presbyterian Village North Special Care Ctr | 1.2 mi | ★★★★★ | 1 | 0 |
| The Highlands Guest Care Center | 1.5 mi | ★★★★★ | 20 | 0 |
| Pure Health Transitional Care At Texas Health Pres | 1.5 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.