Legend Oaks Healthcare and Rehabilitation-Kyle

Inspectors wroteBased on observation, interview, 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 3 of 5 residents (Resident#1, Resident #2 and Resident#3) reviewed for respiratory care. The facility failed to ensure the humidifier water bottle and oxygen cannula connected to the oxygen concentrator of Resident#1, Resident #2 and Resident #3 were changed every Sunday as ordered by the physician. This failure could place residents at risk for respiratory infections through contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medical records were in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, readily accessible; and systematically organized for 3 of 5 residents (Resident#1,Resident #2 and Resident#3) reviewed for respiratory care. The facility failed to ensure LPN A not documenting the of changing of water bottle and oxygen cannula connected to the oxygen concentrator of Resident#1, Resident #2 and Resident #3 as completed on 05/24/26, on MARs, when it was not completed on that day, as ordered by the physician. This failure placed residents at risk for respiratory infections through contamination.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 4 residents (Resident #1, Resident #2, and Resident #3) reviewed for homelike environment. The facility failed to ensure Resident #1's, Resident #2's and Resident #3's privacy curtains were free of stains. This failure could place residents at risk of living in an unclean or unsanitary environment, decreased quality of life, or shame.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be informed of, and participate in, his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for one of (Resident #1) of four residents review for medication changes. The facility failed to ensure Resident #1 was made aware that he was prescribed oseltamivir phosphate (for influenza A prophylaxis) on 01/20/2026. This failure could place residents at risk of receiving medications without their prior knowledge or consent, being unaware of the benefits and risks of the medications prescribed and place residents at risk of diminishing their right to autonomy.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #90) of five residents reviewed for pressure injuries. The facility failed to ensure Resident #90 received wound care treatments for eight days after admission, from 11/26/2025 to 12/04/2025. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. 1. The deep fryer was dirty on 12/09/2025.2. The commercial dishwasher did not meet the minimum required threshold for chemical sanitizing on 12/09/2025. This failure could place residents at risk of food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct an accurate assessment of each resident's functional capacity for 1 of 24 residents (Resident #90) reviewed for comprehensive assessments. The facility failed to ensure Resident #90's pressure wound, present on admission, was included in the admission MDS assessment. This failure placed residents at risk of wound deterioration.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 (Resident #2, Resident #5) of 10 residents reviewed for infection control. The facility failed to properly use EBP personal protective equipment during perineal care for Resident #2 and Resident #5. This failure could place residents at risk for infection transmission, sepsis, and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 4 residents (Residents #3 and Resident #4) reviewed for infection control, as indicated by: MA A did not clean and disinfect the blood pressure monitor while using it on Resident #3 and Resident #4 and failed to keep away opened personal drinks from the med cart , on 11/20/24 at 10:25am . This failure could place the residents at risk of transmission of disease and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (Resident #1) of four residents reviewed for abuse. The facility failed on 11/07/24 to protect Resident #1 from physical and emotional abuse by Resident #2. Resident #2 screamed at Resident #1 and grabbed her right arm with the history of nondisplaced fracture of triquetrum [cuneiform] bone of the wrist, caused erythema (redness of skin) that lasted for 4 days. This failure could place residents at risk of serious physical and emotional injury and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to a dignified existence for 2 of 8 residents (Residents #34 and #67) reviewed for dignity. The facility failed to ensure Resident #34 was wearing clean clothing throughout the day on 09/04/24 and that Resident #67 was wearing clean clothing throughout the day on 09/03/24 and 09/04/24. This failure placed residents at risk of embarrassment and a loss of dignity.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure resident rights for personal privacy for 4 of 10 residents (Resident #5, Resident #14, Resident #92 and Resident #459) reviewed for personal privacy. The facility failed to knock on Residents #5, #14, #92 and #459's room when going into the residents' rooms. The deficient practice could affect all residents right to privacy in the facility and cause the resident to feel like their privacy was being invaded or the facility was not their home.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen observed for food storage, preparation, and distribution. Cook C did not perform hand hygiene appropriately when preparing pureed foods. This failure could place residents who ate food served by the kitchen at risk of food-borne illness from cross-contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents rights to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 5 residents (Resident #49) reviewed for advanced directives: The facility failed to ensure Resident #49's out of hospital do-not-resuscitate (OOH-DNR) form included all required signatures including a second signature from the resident, witnesses, and physician. This failure could place residents at-risk of having their wishes dishonored or delay necessary medical treatment or intervention.

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 grooming and personal hygiene for 1 of 8 residents (Resident #34) reviewed for ADL care. The facility failed to ensure Resident #34's fingernails were clean and smooth from 09/03/24 to 09/05/24. This failure placed residents at risk of skin tears and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents in obtaining dental services for 2 of 5 (Resident #46, Resident #74) residents reviewed for routine dental services in that: The facility failed to assist Resident #46 in obtaining dental services after learning that her dentures were uncomfortable. The facility failed to assist Resident #74 in obtaining dental services after learning her dentures were uncomfortable. These failures could place residents with dental care concerns at risk for pain, declined oral health, weight loss and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 1 of 15 residents (Resident #459) reviewed for call lights. The facility failed to ensure Resident #459's emergency call button in the bedroom was operating properly. This failure could place residents at risk of injury, pain, and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to report alleged violations related to abuse and report the results of all investigations to the proper authorities within prescribed timeframes for one (Resident #1) of five residents reviewed for abuse and neglect, in that: The facility failed to report an allegation of neglect to the State Agency when Resident #1 was found in her room with a steak knife and voicing suicidal intent. This failure placed residents at risk of further abuse or neglect. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to ensure accurate administration and documentation of medications for 1 of 12 residents (Resident #85) reviewed for pharmacy services and medication administration in that: The facility failed to record blood pressure and heart rate as required for Resident #85. This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the walk-in refrigerator/freezer and dry storage were dated and labeled. These failures could affect Residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure Residents have the right to formulate an advance directive for 1 of 18 resident (Resident #31) reviewed for advanced directive in that: The facility failed to have the physician's signature and license number recorded on the Out of Hospital Do Not Resuscitate (OOHDNR) order, which made the advanced directive invalid. This failure could affect any resident in the facility who had an OOHDNR in their chart and place them at risk of having cardiopulmonary resuscitation (CPR) performed against their wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 2 residents reviewed for quality of care (Resident #316). The facility did not maintain physician orders and medical information needed to monitor Resident #316's cardiac pacemaker (electronic device that is implanted in the body to monitor heart rate and rhythm that stimulates the heart with electrical impulses to maintain or restore a normal heartbeat) parameters for proper functioning. This failure could place residents of risk for not receiving proper care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #87) reviewed for dialysis in that: The facility did not maintain communication, coordination and collaboration with the dialysis facility for Resident #87. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were given psychotropic medications to treat specific diagnoses for 1 of 1 Residents, Resident (#74) reviewed for unnecessary psychotropic medications. The facility failed to ensure the medication Aripiprazole (Abilify) was given to treat a specific diagnosis for Resident #74. This failure could affect residents who received psychotropics in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet the residents needs for 1 of 3 residents (Resident #31) reviewed for mechanical soft diet, in that: Resident #31 was provided a whole biscuit cooked hard on the bottom. This failure could place the resident who had physician orders for a mechanical soft diet at risk for choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly, for 1 of 2 dumpsters in that: Dumpster #1 had one half of the top lid open with garbage items visible and on the ground outside the dumpster. This deficient practice could place residents who reside at the facility at risk of unsanitary conditions that could result in the attraction of vermin and rodents and expose them to germs and diseases carried by vermin and rodents.