Legend Oaks Healthcare and Rehabilitation - Waxaha

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and PASRR evaluation report into the resident's assessment, care planning, and transitions of care for 1 (Resident #1) of 2 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting on 04/22/2026. This failure could place residents who have a mental health diagnosis, developmental disability, or intellectual disability at risk from not receiving specialized equipment identified by the IDT in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident's representative of the significant change in the resident's physical, mental, or psychosocial status for two residents (Resident #2 and Resident #3) of ten residents reviewed for resident rights. The facility failed to inform Resident #2's RP she was being transferred to another facility on 3/7/2026. The facility failed to ensure Resident #3's RP was notified when she fell on 3/17/2026 or 3/18/2026. The facility failed to ensure Resident #3's Physician was notified when she fell on 3/17/2026 or 3/18/2026. This failure placed residents at risk of a decreased quality of life and risk of not having their responsible party represent them in medical and care decisions or having their Physician make care decisions post fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one 1 (Resident #1) of ten residents reviewed for quality of care. The facility failed to remove Resident #1's PICC line before he discharged on 3/12/2026. Nurse E failed to report a fall for Resident #3 on or about 3/17/2026 or 3/18/2026. Nurse E failed to assess Resident #3 for injuries after a fall on or about 3/17/2026 or 3/18/2026 These failures placed Resident at risk of injury, infection, not receiving adequate care and services, and decreased quality of life.

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 reviewed. The facility failed to ensure food was properly labeled and dated. This deficient practice could place residents who ate food served from the kitchen at risk for health complications and foodborne illnesses.

Inspectors wroteBased on interviews and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis for 1 of 1 facility's reviewed for qualifications of a Social Worker. The facility, licensed for 121 beds, did not employ a full-time, qualified social worker. This failure could place residents at risk for unmet social services and psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the proper coordination of PASARR assessments for 1 (Resident #41) of 7 residents reviewed for PASARR screenings and evaluations. The facility failed to refer Resident #41 for a PASARR Level II evaluation despite her PASARR Level 1 indicated a diagnosis of MI. This failure could place residents with no PASARR Level II Evaluation at risk of not receiving specialized care and services to meet their needs or obtain their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish a system of accurate reconciliation and removal of expired/discontinued medications from nursing med carts for 1 (500-hall med cart) of 4 med carts reviewed for pharmacy services and medication storage. The 500-hall nursing medication cart had a box of lubricant eye drops labeled for Resident #13 with an expiration date of 01/2026. The 500-hall nursing medication cart had two boxes of wound dressing with antibacterial silver with an expiration date of 07/01/2025. These failures had the potential risk of affecting 24 residents on 500-hall receiving medications from 500-hall med cart which could place them at risk for having non-therapeutic levels of medications and delayed healing.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the open date for insulin for 1 (300-hall med cart) of 4 med carts reviewed for medication storage. The 300-hall nursing medication cart had an insulin pen labeled for Resident #39 and was not labeled with an open date. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of their medications and a decline in health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) for resident records. The facility failed to ensure Resident #1's medication and treatment was documented in PCC for 12/06/2025, 12/09/2025 and 12/11/2025. This failure could place residents at risk for the possibility of not verifying the needed care and services to meet their needs.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents were afforded rights, including the right to self-determination, for 1 of 6 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's Statutory Durable Power of Attorney (DPOA) was appropriately executed in that its elected agents and witness were facility staff, which posed a conflict of interest and the potential for impropriety, and it was implemented during a time in which the resident's capacity to consent was in question. This failure created a dual relationship between the resident and staff and a conflict of interest which could have placed the resident at risk of harm, fraud, exploitation, and/or other legal and medical complications.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of 5 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated to reflect the resident no longer being treated for a yeast infection. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 9 Residents (Resident #162) reviewed for quality of care. The facility failed to ensure Resident #162 made follow up appointment with a wound care specialist. This failure placed residents at risk of condition exacerbation, psychosocial harm, and infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents' environments remained as free from accident hazards as possible for 1 of 9 Residents (Resident #162) reviewed for environmental accidents. The facility failed to ensure Resident #162 was free from environmental hazards and accidents during a 1 person transfer from a wheelchair to a bed. This failure placed residents at risk of physical and psychosocial harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents could receive services with reasonable accommodation of resident's needs and preferences for 1 of 9 Residents (Resident #23) reviewed for accommodation of needs. The facility failed to place Resident #23's call light paddle (which was a white, 0.5 inch by 2.5-inch diameter plastic circular paddle, used to call staff for resident assistance) in a place the resident could reach or activate. This failure placed the residents at risk of having their medical needs unmet and to have experienced psychosocial harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to report allegations of abuse, neglect, exploitation, or mistreatment to the state agency within 2 hours for 1 of 9 Residents (Resident #162) reviewed for required reporting. The facility failed to report an incident of neglect after a failed resident transfer, which resulted in an injury and a 2 day hospitalization. This failure placed residents at risk of continued incidents of neglect.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 2 of 6 residents (Resident #18 and Resident #58) who were reviewed for accuracy of assessments. Resident #18's most recent MDS was coded as resident having clear speech, when observations revealed the resident was only able to make sounds and did not have the ability to carry a conversation. Resident #58's most recent MDS was coded as resident having clear speech, when observations revealed the resident was unable to move her mouth in order to speak. This failure placed residents at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement a comprehensive care plan to meet the resident's highest practicable physical, mental, and psychosocial well-being of 2 (Resident #34 and Resident #82) of eleven residents reviewed for care plans. The facility failed to update the comprehensive person-centered care plan for Resident #34's transfer status for use of the Mechanical lift. The facility failed to implement a comprehensive person-centered care plan for Resident #82 that included Enhanced Barrier Precautions as ordered. These failures could place residents at risk for not receiving appropriate care and treatment.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 1 (Resident #96) of 6 residents reviewed for pharmacy services. The facility failed to monitor Resident #96 for side effects/adverse reactions for the use of Apixaban (an anticoagulant medication- blood thinner). These failures could place residents at risk of bruising, and bleeding.

Inspectors wroteBased on observations and interviews, the facility failed to prepare food that was at an appetizing temperature for one of five residents sampled: 1. The facility served Resident #13 cold or lukewarm food throughout the resident's stay and refused the resident's requests to reheat food items, stating that federal and state regulations did not allow for this. This failure could have placed residents at risk of not being satisfied with their food, decreased food intake, unintended weight loss, hunger, poor nutrition, impeded recovery from illness and injury, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #52 and Resident #82) of eleven residents reviewed for infection control. 1. CNA #A failed to change gloves or wash her hands while performing perineal care when removing a soiled brief and applying a clean brief for Resident #52. 2. The facility failed to ensure staff and others were aware that Resident #82 required the use of Enhanced Barrier Precautions. 3. The facility failed to ensure Personal Protective Equipment (PPE) was readily accessible for the care and treatment of Resident #82, who was on Enhanced Barrier Precautions. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement for his or her quality of life, recognizing each resident's individuality for 2 of 12 Residents (Resident #2 and Resident #3) who were reviewed for quality of life. 3. The facility failed to ensure Resident #2's soiled personal clothing was taken to the laundry. 4. The facility failed to ensure Resident #3's soiled personal clothing was taken to the laundry. This failure could place residents at risk of odorous living conditions, embarrassment, and diminished feelings of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safety, for 2 of 12 Residents (Resident #2 and Resident #3) reviewed for safe and clean environment. 1. The facility failed to ensure Resident #2's soiled personal clothing was taken to the laundry. 2. The facility failed to ensure Resident #3's soiled personal clothing was taken to the laundry. This failure could place residents at risk of odorous living conditions, embarrassment, and diminished feelings of self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's, to meet the needs of the resident for 1 of 1 Residents (Resident #1) reviewed for pharmaceutical services. The facility failed to administer the correct dosage of medication to Resident #1. This failure could place residents at risk for mental anguish and medically adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision for one (Resident #1) of five residents reviewed for accidents and hazards, in that: The facility failed to assist and monitor Resident #1 during meal service on 02/20/24 when she was served dinner despite a hospice order dated 02/11/24 stating that she should be assisted with meals and not left alone with food, and Resident #1 choked and was subsequently sent to the ER where she was diagnosed with aspiration pneumonia and remained hospitalized until 02/25/24. An Immediate Jeopardy (IJ) was identified on 03/05/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 3 residents (Resident #2) reviewed for care plans. Resident #2 did not have completed comprehensive care plans for resident needed supervision or touching assistance while eating. This deficient practice could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 18 Residents (Resident #1 and Resident #2) reviewed for accidents and hazards. 1. The facility failed to ensure Resident #1 received microwaved food, from an outside source, at a temperature for safe elderly consumption which resulted in a second-degree burn. 2. The facility failed to ensure Resident # 2 had total assistance while consuming a cup of hot coffee resulting in medical attention for skin irritation. On 2-5-2024 at 7:54 PM an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received treatment and care with professional standards of practice for 1 of 19 Residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 received immediate medical care after he spilled a bowl of [steaming] soup on his right lower torso area, which caused a 2nd degree burn. The incident went unreported and undetected for 1 calendar day. This failure placed residents at the facility at risk for unmet medical attention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for one of one (MC 1) overflow medication carts reviewed for medication storage. The overflow medication cart (MC 1) on the 400 hallway, was observed to be unattended and unlocked. This failure could place residents, unauthorized staff and visitors at risk for drug diversion and access to medications that could cause physical harm, permanent injury or even death.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of ten residents reviewed for changes in condition, in that: The facility failed to notify the responsible party (FM F) for Resident #1 when he developed skin breakdown in his perineal area and required treatment. This failure placed residents at risk of a lack of a dignified existence, self-determination, and quality of life .

Inspectors wroteBased on observation, interview, 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 forfor one (1) (Resident #1) of 10 residents reviewed for pressure wounds, in that: The facility failed to ensure that CNA D reported a pink area on Resident #1's left buttock to the nurse for further assessment. This failure placed 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 resident review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one of three residents (Resident #1) reviewed for tube-feeding. The facility failed to ensure Resident #1's enteral formula was increased from 20 ml to 60 ml according to a titration order during the first 24 hours of his stay in the facility beginning the evening of 09/22/23. He received only 20 ml per hour until the morning of 09/25/23. This failure placed residents at risk of weight loss, dehydration, and associated discomfort. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for three (residents #62, #63, and #64) of three residents reviewed for infection control. MA #A failed to disinfect the electric Blood Pressure Cuff (an instrument for measuring the blood pressure) in between resident use for resident #62, #63, and #64. This failure could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 3 of 7 residents (Residents #3, #39 & #51) reviewed for call lights in that: Residents #3, #39 & #51's call lights were not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observation, interview and record review the facility failed to provide routine nail care for 1 Resident #61) reviewed for routine nail care. This deficient practice to provide grooming assistance put the resident at risk to scratching himself and possible skin infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide appropriate services to prevent complications with catheters for 1of 2 Resident idents (Resident ident# 12) who were observed for catheter care. The facility failed to ensure that Resident # 12's catheter bag placement and tubing were free from large coils to allow free flow of urine from the Resident ident to the catheter bag. This could place residents at risk for discomfort and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medications errors for one of three residents (Resident #62) reviewed for medications. MA #A failed to verify Resident #62's pulse parameters order prior to administering Losartan 25mg. Losartan would have been administered had the Surveyor not stopped and had her recheck the order for parameters related to pulse lower than 60 beats per minute. This failure could have placed residents at risk for Dizziness, chest pain, fast or irregular heart rate, and hypotension (low blood pressure).