Legacy Nursing and Rehabilitation

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen.1. The facility failed to properly thaw ground beef and turkey in the sink, under running water, in its kitchen on 02/10/2026.2. The facility failed to properly store, label, and date all food items located in the facility refrigerators, freezers and in the dry food pantry area on 02/10/2026 and 02/11/2026. 3. The facility failed to discard outdated food items located in the refrigerator and dry food pantry on 02/10/2026 and 02/11/2026. 4. The facility failed to ensure that dietary staff wore hair restraints (e.g. beard restraints) to prevent hair from contacting food, according to the current Food Code on 2/11/2026. 5. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents had a right to organize and participate in resident groups for six of six confidential residents reviewed for resident council. The facility failed to provide monthly Resident Council meetings for the month of October 2025 and January 2026. This failure could place residents at risk of not being able to exercise their rights to meet as a group.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 (Residents #41, #50 and #69) of 8 residents reviewed for activities. The facility failed to provide activities for Resident #41, Resident #50, and Resident #69 for the months of January and February 2026. This failure could place residents at risks of boredom, depression, and diminished quality of life and decreased cognitive function.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 5 medication carts (Medication Cart #1 and Medication Cart #2) reviewed for medication storage. The facility failed to ensure Medication Cart #1 and Medication Cart #2 were locked and medications were secured and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the counter medications.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for one (1) of five (5) residents (Resident #64) reviewed for accuracy of assessments. The facility failed to ensure the MDS dated [DATE] was updated to reflect active dialysis for Resident #64 The facility failed to ensure the MDS dated [DATE] was updated to reflect active dialysis for Resident #64 This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Record review of Resident #64's Face sheet dated 02/10/2026, reflected he was a [AGE] year-old male, who was admitted to facility on 10/25/2025 with readmission on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three of eight residents (Resident # 57 and Resident #59) reviewed for ADL care. The facility failed to ensure Resident #10, Resident #50 and Resident #69's nails were cleaned and did not have any rough edges on 02/10/2026. This failure could place residents at risk of not receiving services or care, diminished quality of life , and decreased self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to have sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for one cook (Cook B) of three dietary cooks reviewed for qualified dietary staff in that:Cook B had not received the Texas food handler certificate to carry out the functions of the food and nutrition services department. This failure could place residents at risk of not having their nutritional needs met and place them at risk of food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to immediately notifies the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition for 1 of 3 residents (Residents #1) reviewed for hospice services. The facility failed to immediately notify resident's hospice provider of COC, transport by EMS, and discharge to hospital. This deficient practice could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the right to be free from Misappropriation of Resident Property for 3 of 5 residents (Residents #1, #2 and #3) The facility failed to prevent the misappropriation of Resident #1's discontinued Hydrocodone/ Tylenol 7.5mg/ 325mg when 10 tablets could not be accounted for and Resident #2's hydromorphone liquid 1mg/ml when 120 ml could not be accounted for, and Resident #3's Hydrocodone/ Tylenol 10 mg/ 325mg when 56 tablets could not be accounted for. The noncompliance was identified as PNC. The past noncompliance began on 05/29/2025 and ended on 06/04/2025. The facility had corrected the noncompliance before the investigation began. This failure had the potential to affect the residents in the facility by placing them at risk for misappropriation of resident medication and drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one resident (Resident #50) of 23 residents reviewed for nutrition. The facility failed to ensure Resident #50 maintained acceptable parameters of nutritional status as demonstrated by Resident #50 experiencing a 10.98% weight loss in less than 60 days. These failures could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that the medication error rate was not five percent or greater when the facility had a medication error rate of 9.68% based on 3 of 31 opportunities, which involved 2 of 5 residents (Resident #39, and Resident #63) and 1 of 2 MA's (MA D) observed during medication administration. A) Resident #39 had physician orders for Lisinopril 20 mg one tablet by mouth two times a day hold if BP is below 100/60 mm/hg and Metoprolol Tartrate 25 mg give 0.5mg tablet by mouth two times a day to keep pulse in normal range of 60 to 60 and to hold if BP was below 100/60 or pulse 55 bpm. MA D did not check Resident #39's vital signs prior to administering her medication on 11/13/2024 and no blood pressures were documented for November 2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's kitchen and nourishment room. -The facility failed to ensure food and beverages stored in the walk-in cooler were labeled and dated. -The facility failed to remove the scoop for dry goods stored in large bins for sugar, flour, and thickener powder on 10/14/2024. -The facility failed to clean and sanitize the resident nourishment room refrigerator which had expired foods and an unknown brown substance in a bag. These failures could place residents who ate food from the kitchen, nourishment refrigerator and ice machine at risk of foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop a comprehensive care plan for one resident (Resident #31) of 23 reviewed, in that: The facility failed to ensure Resident #31's Comprehensive Care Plan reflected a revision of care for his current skin condition and wound care. This failure could place a resident at risk for errors in provider care, and wound tracking.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of eight residents (Resident # 34 and Resident #75) reviewed quality of life. 1. The facility failed to ensure Resident #34 nails were cleaned and did not have any rough edges on 11/12/2024. 2. The facility failed to ensure Resident #75 facial hair was removed on 11/12/2024. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident # 61) of four residents reviewed for accidents and hazards. The facility failed to ensure Resident #61 intervention of a fall mat was placed on the side of the bed on 11/13/2024. This failure could result in residents experiencing accidents, injuries, unrelieved pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 1 of 10 Residents (#34) reviewed for accommodation of needs, in that:. Resident #34 was observed in her room with her call light not in reach. This failure could affect residents who needed assistance and could result in needs not being met.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to be free from any physical or chemical restraints imposed for purposed of discipline or convenience and not required to treat the resident's medical symptoms and, when the use of restraints was indicated, to use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints for one of two residents (Residents #43) reviewed for restraints, in that: Resident #43 was physically restrained in a wheelchair with a Velcro seat belt without a plan of care for the device. These deficient practices could place residents who were at risk for falls and/or wandered at risk of unnecessary confinement. Finding Included: [...]

Inspectors wroteBased on record review and interview the facility failed to transmit resident assessments within the required time frames for 2 of 10 Residents (#27 and #34) reviewed for MDS assessments. A) The facility failed to complete and submit a discharge MDS for Resident #27. B) The facility failed to submit a Quarterly MDS for Resident #34. These failures could place residents at risk of not having their resident specific information submitted for payment and quality measure purposes.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a person-centered care plan to maintain a resident's practicable wellbeing for one of two residents (Resident #43) reviewed for restraints and one of one resident (Resident #41) reviewed for bed rails. A) The facility failed to ensure Resident #43 who was physically restrained in a wheelchair with a Velcro seat belt without a plan of care for the device. B) Resident #41 was observed in bed with full bed rails on both sides of the bed. Resident #41 did not have a plan of care for the full bed rails. This deficient practice could place residents who were at risk for falls and/or wandered at risk of unnecessary confinement and could place residents at risk for entrapment. Finding Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of two (Resident #22) residents reviewed for pressure ulcers. The facility failed to ensure Resident #22 received his physician ordered pressure ulcer preventative measures routinely. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for 1 of 5 Residents (#34) reviewed for accidents hazards, in that:. Resident #34 was observed in her bed with her bed in a high position and her fall mat not positioned in place beside her bed. This failure could affect residents at risks for accidents and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 2 of 4 Residents (Resident #55 and #46) reviewed for respiratory care. A) The facility failed to ensure Resident 55's oxygen tubing was changed weekly. B) The facility failed to ensure Resident #46's oxygen tubing was covered when not in use. This failure could place all residents who use respiratory equipment at risk for respiratory infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation for one of one resident (Resident #41) reviewed for bed rails Resident #41 was observed in bed with full bed rails on both sides of the bed. Resident #41 did not have a plan of care for the full bed rails or an assessment for entrapment risk in the resident's record. This deficient practice could place residents at risk for entrapment with injury. Findings Included: Review of Resident #41's Face sheet dated 09/27/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. [...]