Legend Oaks Healthcare and Rehabilitation -Garland

Inspectors wroteBased on observation, interview, and record review, the facility failed, in accordance with State and Federal laws, to ensure medications and biologicals were stored in a safe and secure manner and were not accessible to residents #17 & #21. 1. The facility failed to ensure Resident #17 did not have access to an open tube of Clear Moisture Barrier Ointment observed on the bedside table in plain view on 4/28/26. 2. The facility failed to ensure Resident #21 did not have access to an unopened packet of Essentials Prevent Ointment observed on the bedside table in plain view on 4/28/26. These failures could place residents at risk for accidental misuse or ingestion of topical medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two of twenty residents (Resident #93 and Resident #95) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #93 and Resident #95's rooms were in a position that was accessible to the residents on 04/28/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of three residents (Residents #17) reviewed for quality of care. The facility failed to ensure that Resident #17's open wounds to her left and right buttocks were covered with dressings on 04/28/2026. This failure could place the residents with open wounds at risk for infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident's environment remained free of hazards as was possible for one of six residents (Resident #24) reviewed for accident hazards. The facility failed to ensure Resident #24 had physician orders for a scoop mattress to ensure it was not a hazard for the resident. This failure could prevent the residents from having an environment that was free from accidents, and potential injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one of three residents (Resident #29) reviewed for feeding tube management. The facility failed to ensure LVN D flushed Resident #29's g-tube before and after medication administration as ordered on 04/29/2026. This failure could place residents with g-tubes at risk for clogging.

Inspectors wroteBased observation, interview, and record review 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 two of twelve residents (Resident #73, and Resident ##81) reviewed for infection control.1. The facility failed to ensure LVN D placed a cap on Resident #73's IV port after disconnecting the resident's IV on 04/28/2026.2. The facility failed to ensure on 04/28/2026 CNA E wore a gown while performing Resident #81's incontinent care, who had a permacath and was undergoing dialysis, and was on enhanced barrier precautions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of seven residents (Resident #1, Resident #2) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free from abuse by Resident #2, who threw an empty plastic bowl at Resident #1. This failure could place residents at risk for abuse or neglect that could lead to serious harm.

Inspectors wroteBased on interview and record review the facility failed to provide care and services, based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for one of seven residents (Resident # 3) reviewed for activities of daily living. The facility failed to ensure Resident #3 was provided with incontinent care in a timely manner. This failure could place residents at risk for poor self-esteem, infection, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one (Residents #1) of ten residents and for one (Crash Cart) of three carts reviewed for medication storage. The facility failed to ensure the crash cart (cart stocked with medical equipment, supplies, and medications used during medical emergencies) was locked on 12/30/2025. The facility failed to ensure a tube of pain relieving topical (application of medication through the skin) analgesic (painkiller) cream was not inside Resident #1's room on 12/30/2025. These failures could place the residents at risk of accessing/opening the cart, accidental overdose, adverse reactions, misuse of medications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's sleep apnea mask was properly stored in a bag when not in use on 09/30/25. The facility failed to ensure Resident #1's nebulizer mask was properly stored in a bag when not in use on 09/30/25. The facility failed to ensure Resident #1's nasal canula attached to the oxygen tank on his wheelchair was properly stored in a bag when not in use on 09/30/25. These failures could place the resident at risk for respiratory infection and not having his respiratory needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 13.33% based on four errors out of 30 opportunities, which involved three (Resident #28, Resident #74, and Resident #89) of six residents reviewed for medication errors. 1. The facility failed to ensure Resident #28's Glipizide (lowered blood sugar) and Benzonatate (treats cough) was administered as ordered during the scheduled timeframe of 7:00 a.m. to 10:00 a.m. 2. The facility failed to ensure Resident #74's Carvedilol (treats high blood pressure) was administered as ordered during the scheduled timeframe of 7:00 a.m. to 10:00a.m. 3. The facility failed to ensure Resident #89's Metformin (lowers blood sugar) was administered as ordered during the scheduled timeframe of 7:00 a.m. to 10:00a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure that food items past there expiration date were discarded. This failure could place residents at risk of exposure to food borne illnesses.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that each resident had a right to personal privacy and confidentiality of his or her own personal medical records for 1 (Resident #94) of 2 residents investigated for privacy of medical records. The facility failed to ensure when Resident #93 discharged from the facility Resident #94's Personal Private Information was not handed to Resident #93's Resident's representative. This failure could place residents at risk of having medical information exposed to others and possible misuse of personal information.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 11 (Resident #1, 14, 15, 23, 36, 48, 51, 52, 56, 70, and 80's) of 27 resident rooms observed for housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The facility failed to ensure that Resident #1, 14, 15, 23, 36, 48, 51, 52, 56, 70, and 80's rooms were cleaned, sanitized, and maintained. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 3 of 6 (Resident #14, #49, and #63) residents reviewed for restraints. The facility failed to ensure Residents #14 and Resident #63 had physician orders or a physician assessment for a scoop mattress. The facility failed to ensure Resident #49 had physician orders or a physician assessment for a large positioning wedge to be added to her bed. These failures could unnecessarily inhibit the residents' freedom of movement or activity.

Inspectors wroteBased on interviews, and record review the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 3 residents (Residents #1, and #36) reviewed for ADLs care provided to dependent residents. The facility failed to ensure Resident #1, and #36 received showers consistently based on records reviewed for January 2024 and December 2023. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Included: Resident #1 Record review of Resident #1's face sheet dated 01/18/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnosis included amputation below left and right knee. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 (Resident #14, #15, #55, and #67) of 6 residents reviewed for respiratory care. The facility failed to ensure Resident #14's tubing on his Nebulizer machine was changed within the facility policy of 7 days. The Facility failed to ensure Resident #15's mask and tubing for his BiPAP machine was cleaned and sanitized. The facility failed to ensure Resident #55's nebulizer mask was properly stored and dated. The facility failed to ensure Resident #67's humidifier had water in it. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure that four (Resident #3, Resident #12, Resident #56, and Resident #58) of fifteen residents were provided medications and/or biologicals and pharmaceutical services to meet their needs. The facility failed to ensure CMA B and LVN N re-ordered medications on a timely manner for Resident #3 (Clopidogrel Bisulfate 75 mg), Resident #12 (Gabapentin capsule 100 mg), Resident #56 (Oxcarbazepine 300 mg) and Resident #58 (Levothyroxine Sodium 25 mcg). This failure could place the residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. The facility failed to ensure food in the freezer was not exposed from air-borne contaminants. The facility failed to ensure the ice machine, located in the facility's kitchen, was thoroughly cleaned. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 6 residents (Resident #28) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #28 prior to administering Lamictal (medicine to treat seizures and bipolar disorder). This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the risk of the medications prescribed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #68 and Resident #236) of twelve residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents # 68 and #236's rooms was in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to make information on how to file a grievance or complaint available to the residents, including notifying residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing for 1 of (Resident #71) of 3 residents reviewed for grievances. 1. The facility failed to ensure Resident #71 knew how to file a grievance. The facility's failure could place the residents at risk for concerns not being reported and addressed.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #44) of three residents reviewed for care plans. The facility failed to ensure a fall mat was in place per the care plan for Resident #44. This failure could place residents at risk for not receiving care consistent with their care plan.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #76) of one resident reviewed for gastrostomy tube management. The facility failed to ensure Resident #76 had an order for the enteral feeding (intake of food directly into the stomach) downtime. This failure could place residents at risk for underfeeding or overfeeding.

Inspectors wroteBased on observation, interview, and record review 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 (Resident #43 and Resident #18) of 8 residents reviewed for infection. 1. The facility failed to ensure ADON R washed or sanitized her hands before putting on the resting hand splint to Resident 43's right hand. 2. The facility failed to ensure CNA C performed hand hygiene during incontinence care for Resident #18.

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 8 of 10 sharp containers reviewed for accidents and hazards. The facility failed to ensure staff changed sharps containers prior to them becoming overfilled and becoming a hazard. This failure could place residents at risk of injury or exposure to needles contaminated with unknown biological agents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from any physical or chemical restraints imposed for the purpose of disciplie or convenience for 1 (Resident #1) of four residents reviewed for chemical restraints. The facility failed to ensure LVN A did not sedate Resident #1 with a medication not prescribed for her. This failure could place the residents at risk of injury or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services which included procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 4 residents (Resident #2) reviewed for medication administration. 1. The facility failed to ensure LVN C administered Resident #2's medications as ordered. 2. The facility failed to ensure a discontinued medication, Xanax, for Resident #1 was removed from the medication cart on 05/30/23, which resulted in the resident being administered the drug without physician orders. The failures could place residents at risk of not receiving their medications as ordered and adverse drug reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for one of four residents (Resident #1) reviewed for medications. LVN A failed to ensure Resident #1 was not administered the psychotropic drug, Xanax, on 10/02/23 that had been discontinued by the physician on 05/30/23. The failure could place residents at risk of serious adverse drug reactions.