Legend Oaks Healthcare and Rehabilitation Center G

Inspectors wroteBased on interview, and record review, the facility did not ensure treatment and services was provided, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 1 of 3 residents reviewed for quality of care. (Resident #1)The facility failed to implement treatment orders for Resident #1's right heel as ordered by Wound Care Specialist from 5/11/2026-5/18/2026. This failure could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries.

Inspectors wroteBased on observations, interviews, and record review the facility to ensure residents were informed orally of their rights for 8 of 8 confidential residents reviewed for resident rights. The facility failed to ensure residents were provided ongoing communication of their rights during their stay at the facility. This failure could place residents at risk for a decreased quality of life and awareness and execution of their rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided reasonable access to receive their mail in a timely manner for 8 of 8 confidential residents reviewed for mail. The facility failed to implement a system to distribute incoming mail daily and ensure residents promptly received their mail. This failure could place residents at risk of a delay in residents' personal correspondence, financial information, or other time-sensitive materials.

Inspectors wroteBased on observations, interviews and record review the facility failed to make information available to residents and their representatives on filing grievances for 7 of 8 confidential residents reviewed for grievances. The facility failed to ensure residents and their representatives had access to grievance forms and accommodations to file an anonymous grievance. This failure could place residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on interviews and record review the facility failed to provide, based on the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 8 of 8 confidential residents reviewed for activities. The facility failed to provide activities to meet the residents' interests on the weekends. This failure could place residents at risk for a decline in quality of life and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a system was established for records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determined that all drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 2 of 4 licensed nurse medication carts (100 and 300 hall carts) observed for pharmacy services. 1. The facility failed to ensure RN A did not sign the controlled substance count sheets for the end of their shift at the beginning of their shift on Cart #300 hall, on 04/14/2026. 2. The facility failed to ensure LVN B signed as receiving the controlled substance count sheets for his shift on Nurses Cart #100 on 04/14/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 2 of 3 residents (Resident #2 and Resident #3) reviewed for urinary catheters. The facility failed to ensure Resident #2's foley catheter was secured and/or anchored to prevent complications. The facility failed to ensure Resident #3's suprapubic catheter was secured and/or anchored to prevent complications. These failures could place residents with urinary catheters at risk for damage to the bladder or urethra, dislodging of the catheter, and urinary infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of four medication carts (Hall 100 medication cart) reviewed for labeling and storage. The facility failed to ensure LVN B locked the hall 100 medication cart when it was unattended. This failure could place residents at risk of drug diversion, administration of incorrect medication and compromised resident safety.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #27 and Resident #65) reviewed for Infection Control. The facility failed to correctly identify residents who required EBP. The facility failed to provide consistent identification of residents who required EBP. The facility failed to ensure Resident #65 who had 2 (two) surgically inserted drainage tubes was on EBP. These failures could place residents at risk for the development and transmission of communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post their most recent survey of the facility in an area of the facility accessible to residents, and family members and legal representatives of residents, in 1 of 1 survey binder. The facility failed to ensure the most recent standard survey dated 02/12/2025 was readily available within the survey binder. This failure could place residents at risk for not having access to current information regarding the facility's compliance with federal and state regulations, limiting their ability to make informed decisions and exercise their rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the nurse staffing data on a daily basis, in a clear and readable format and in a prominent place, and readily accessible to residents and visitors that included the facility name, the number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care for 7 of 7 days (April 7-13, 2026) reviewed for posting of nurse staffing data. The facility failed to post the required nurse staffing information on 04/07/2026, 04/08/2026, 04/09/2026, 04/10/2026, 04/11/2026, 04/12/2026, and 04/13/2026. This failure could place residents at risk for adverse resident outcomes due to understaffing and loss of public trust.

Inspectors wroteBased on interview and record review 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 no later than 24 hours after the allegation was made, for 1 of 3 residents (Resident's #1) reviewed for abuse and neglect. The facility failed to report an allegation of neglect on 01/19/2026 to HHSC within 24 hours. This failure could place the residents at increased risk for abuse and neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1 had appropriate footwear on while she sat in her wheelchair in the dining room on 1/21/26. This failure could place residents at risk of falls and significant injury.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents reviewed received reasonable accommodation of needs for 3 of 20 residents (Resident#2, Resident #27, Resident #52) reviewed for resident rights. The facility failed to ensure Resident #2, Resident #27, and Resident #52 had a call light within reach. This failure could place residents at risk of injury that could lead to falls, major injuries, hospitalization, and unmet needs.

Inspectors wroteBased on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 3 of 20 reviewed for medication storage. (Resident #2, Resident #27, Resident # 163) 1. The facility failed to securely store 3 packets of Thera calazinc barrier cream and a medication cup with a white substance located on Resident #2's beside table. 2. The facility failed to securely store over the counter medication Miconazole Nitrate 2% cream for Resident #27 which was located on the bedside table. 3. The facility failed to securely store prescribed medication Silvadene 400 gm and Adapt stoma powder for Resident #163 which was located on the bedside table. The failures could place residents at risk for health complications and not having received the intended therapeutic benefit of their medications and adverse reaction.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 24 residents (Residents #18, #46 and #51) reviewed for infection control practices. 1. The facility failed to ensure CNA G performed proper incontinent care. CNA G wiped from the top of Resident #18's buttocks down towards the perineal area during incontinent care. 2. The facility failed to ensure the proper disinfectant cleaner was used to clean Resident #51's isolation room. Resident #51 had Clostridium difficile (bacteria that causes infection in the large intestine). 3. LVN B did not change her gloves or sanitize her hands after performing catheter care for Resident #46. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 1 resident (Resident #51) reviewed for respiratory care and services. The facility failed to ensure Resident #51's oxygen concentrator was clean and free of gray debris. This failure could place residents who receive oxygen at risk for developing respiratory complications.

Inspectors wroteBased on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 9 kitchen staff (Dietary Aide A) reviewed for qualified dietary staff. The facility failed to ensure the DA A met the requirements for food handling by obtaining a current and valid Food Handler's Certificate. This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide liquids consistent with the resident's needs, for 1 of 24 (Resident #21) residents reviewed for liquid inconsistency, in that: The facility failed to ensure CNA C did not serve ice water on 2/11/25 to Resident #21 who required nectar-thickened liquids. This failure could place residents who have dysphagia at risk for aspiration (breathing on foreign objects).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 11 residents reviewed for abuse. (Resident #1) The facility failed protect Resident #1 from abuse when RN A recorded him on 07/26/24 with her personal cellphone while undressed from the waist down. RN A was laughing. RN A showed and sent the video to other staff. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for emotional and mental abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 11 residents (Resident #1) reviewed for abuse and neglect. The facility failed to prevent Resident #1 from being abused when on 07/26/2024 RN A entered his room and filmed him with her cellphone. Resident #1 was naked from the waist down. RN A shared the video with other staff. The facility failed to protect Resident #1 from potential further abuse after the allegation. RN A was allowed to work from the date of the incident until she was suspended on 08/22/24. The facility staff (RN B, LVN C, CNA D, LVN E, the Staffing Coordinator, the Transport Aide, PTA L) failed to report abuse immediately to the Abuse Coordinator after they had viewed or became aware of the video. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment are reported immediately or not later than 2 hours for 1 of 11 residents reviewed for abuse and neglect. (Resident #1) The facility staff (RN B, LVN C, CNA D, LVN E, the Staffing Coordinator, the Transport Aide, PTA L) failed to report abuse immediately to the Abuse Coordinator after they had viewed or became aware of video taken by RN A of Resident #1 naked from the waist down. Facility Administrator G failed to investigate and to report an allegation of abuse to the state agency after he became aware of the video on 07/31/24. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 of 11 residents reviewed for abuse. (Resident #1) The facility Administrator, Administrator G, failed to investigate an incident where RN A videoed Resident #1 in his room naked from the waist down. RN A shared the video with other staff. The facility failed to protect Resident #1 from potential further abuse after the allegation. RN A was allowed to work from the date of the incident until she was suspended on 08/22/24. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for further abuse, physical or psychological harm or injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an effective pest control program so the facility was free of pests for 1 of 3 residents reviewed for pest control. (Resident #2) The facility had an outbreak of flies during the week of 5/23/24 through 6/5/24. On 6/1/24 a Resident #2 was noted with maggots in his wounds on his foot. This failure could cause the facility to become infested with pests.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 3 residents reviewed for quality of care. (Resident #2 and Resident #1) Resident #2 and Resident #1 did not receive physician ordered wound care as ordered by the physician according to the manufacture's recommendations for treatment with Hydrofera Blue (a medicated foam dressing for wounds) that required moisture before use. The facility failed to ensure Resident #2's physician's plan of care for a boot that was an appropriate fit to prevent an increased risk for injury to his right foot as ordered by the physician. This failure could cause residents to not attain or maintain their highest physical well-being. Findings Included: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents had the right to be free from involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 1 of 4 (Resident #1) residents reviewed for involuntary seclusion. The facility failed to follow their policy for residents refusing the test for COVID-19 resulting in Resident #1 being placed in isolation from 7/18/23 through 8/18/23 (32 days), 10/3/23 through 10/16/23 (13 days), and 11/6/23 through 11/11/23 (6 days). This failure could place residents at risk for increased depression and emotional and psychological harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 (Resident #1 and Resident #2) residents reviewed for infection control. 1. The facility failed to ensure they used the least restrictive isolation possible for Resident #1 when he was put in isolation from 7/18/23 through 8/18/23 (32 days), 10/3/23 through 10/16/23 (13 days ), and 11/6/23 through 11/11/23 (6 days) due to refusing to be COVID tested. 2. The facility failed to ensure CNA F did not use contaminated wipes and gloves when performing in continent care on Resident #2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 1 facility reviewed for resident rights. The facility did not allow visitors between the hours of 10:00 p.m. to 8:00 a.m. except in the event of end of life. This failure could place residents at risk for emotional and psychological harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure BIMS assessments accurately reflected the status for 3 of 16 residents reviewed for assessments. (Resident #'s 28, 33, and 45) 1. The facility failed to ensure Resident #45's admission MDS assessment dated [DATE] and his Quarterly MDS assessment dated [DATE] accurately reflected his cognitive status. 2. The facility failed to ensure the Resident #28's Quarterly MDS assessment dated [DATE] accurately reflected her cognitive status. 3. The facility failed to ensure the Resident #33's Annual MDS assessment dated [DATE] accurately reflected his cognitive status. This failure could place residents at risk of not having individual needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 5 or 20 residents (Resident #16, Resident #22, Resident #33, Resident #39, and Resident #56) reviewed for respiratory care. 1. The facility failed to properly store a nebulizer mask while not in use for Resident #56. 2. The facility failed to ensure Resident #16 and Resident #33 CPAP mask (a hose connected to a mask or nosepiece to deliver constant and steady air pressure to help you breathe while you sleep) was stored in a bag after use. 3. The facility failed to ensure Resident #22's nebulizer mask (provide vaporized medicine into the airway) was stored in a bag after use. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or For excessive duration; or Without adequate monitoring; or Without adequate indication for its use; or In the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 2 of 5 residents (Resident #16 and Resident #33) reviewed for unnecessary medications in that: The facility failed to ensure Resident #16 had behavior monitoring (is an on-going process to evaluate a person's distressed behaviors, including: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs for 1 of 1 medication rooms reviewed for storage of medication. The facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #45) of 16 residents reviewed for pharmacy services. 1. The facility failed to ensure the narcotic box was permanently affixed inside the refrigerator in Medication room [ROOM NUMBER]. 2. The facility failed to ensure accurate medication administration and securely store Resident #45's Hydrocodone, Colace, Eliquis, Famotidine, Furosemide, Guaifenesin, Movantik, Lyrica, and Milk of Magnesia that were at the resident's bedside. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 16 residents (Resident #16 and Resident #33) reviewed for reasonable accommodations. The facility failed to ensure Resident #16 and Resident #33's call light was placed within reach. This failure could place residents at risk for unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations, for 1 of 7 staff (RN T) reviewed for abuse/neglect. The facility's staff members (LVN D, RN H, LVN Q, LVN R, CNA K, CNA U, CNA N) failed to immediately report RN T suspicious behaviors and behaviors that may indicate an impaired individual to the ADM and DON. The facility hired RN T, who had active disciplinary action against her nursing license per the Texas Board of Nursing, which was against their policy. These failures could place residents at risk of abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 16 residents (Residents #16 and Resident #33), reviewed for care plans. 1. The facility failed to revise and update Resident #16's comprehensive care plan for his functional abilities related to shower/bathing and eating. 2. The facility failed to revise and update Resident #33's comprehensive care plan for his functional abilities related to eating, shower/bathing, and personal hygiene. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on observation, interview, and record review, the facility has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 2 residents reviewed for transfer. (Residents #33) The facility failed to ensure CNA N performed a safe 1 person transfer for Resident #33 due to not using a gait belt during transfer. This failure could place residents at risk of injury from accident and hazards.

Inspectors wroteBased on interview and record review the facility failed to have adequate monitoring in place for side effects associated with the use of psychotropic medications and documented in the clinical record for 1 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #33). The facility failed to ensure Resident #33 had behavior monitoring for his prescribed anti-anxiety (treats anxiety disorders). The facility failed to ensure Resident #33 had side effect and effectiveness monitoring for his prescribed anti-anxiety. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for two of two residents (Resident #1 and #2) reviewed for accidents and hazards in that: 1. The facility failed to update Resident #1's elopement evaluation after he exhibited exit seeking behavior, and Resident #1 was able to elope from the facility without staff's knowledge due to an exit door failing to activate and Resident #1 was found on the roadway by police 2. The facility failed to ensure coffee was served at a safe temperature for Resident #2. Resident #2 received second degree burns to the left arm and abdomen after hot coffee was spilled on her. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents the right to be free from abuse and/or neglect for 1 (Resident #3) of 10 residents reviewed for abuse and/or neglect. 1. The facility failed to prevent OT A from pulling Resident #3's arm down while Resident #3 was receiving therapy in the therapy gym. 2. The facility failed to prevent OT A from using a loud tone of voice with Resident #3 in the therapy gym after Resident #3 complained he wanted to be finished with his therapy session These failures could place residents at risk of physical or emotional harm.