Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legend Oaks Healthcare And Rehabilitation Center - during CMS and state inspections, most recent first.
The facility failed to include the use of bed rails in the care plans for three residents, despite their medical conditions and cognitive impairments. Observations confirmed the consistent use of bed rails without documentation in the care plans, and the DON acknowledged the requirement for physician orders, consent, and care plan inclusion, which was not met.
The facility failed to assess and document the use of bed rails for three residents, leading to a deficiency in care. Residents with severe impairments were not evaluated for alternatives or risks of entrapment before bed rails were installed. Observations showed residents with bed rails up, and necessary documentation and care planning were inadequate.
The facility failed to store and handle food according to professional standards, with an opened bag of cheese and unsealed cooked pork found in the cooler, both lacking proper sealing and labeling. Additionally, a mop was improperly stored, preventing air drying. These actions were contrary to the facility's policies based on the Texas Food Establishment Rules and the U.S. Public Health Service Food Code.
A facility failed to properly document a resident's DNR order, leading to potential risk of unwanted CPR. The resident's DNR was incomplete, lacking necessary signatures, and the social worker was unaware of its status. The resident's responsible party did not complete the DNR form and was concerned about a forged signature. Facility policy on advance directives was not followed.
Two residents with indwelling urinary catheters received inadequate care, risking urinary tract infections. One resident's catheter bag was not properly managed, while another received improper cleaning, leading to a UTI diagnosis. Both CNAs had completed training but failed to follow procedures.
The facility failed to maintain proper communication and documentation for two residents requiring dialysis. For one resident, forms were incomplete, missing signatures, and lacked confirmation of communicated information. Another resident's forms were incomplete, and a missed dialysis session was not properly documented. The facility did not adhere to its policy for ongoing communication with the dialysis facility, risking inadequate care.
A facility failed to coordinate hospice care and maintain proper documentation for a resident receiving hospice services. The resident's plan of care, DNR, and hospice physician orders were not available in the hospice binder or electronic medical record. Interviews revealed that the DON and SW were unaware of the location of these documents, risking inadequate end-of-life care. The facility's policy requires individualized care plans and collaboration with hospice, which was not followed.
The facility failed to maintain proper infection control practices for two residents with indwelling urinary catheters. In one case, a CNA did not perform hand hygiene after glove removal during catheter care, risking cross-contamination. In another case, a resident's catheter tubing was found touching the floor, and staff did not use enhanced barrier precautions as required. These lapses were acknowledged by the DON and could increase infection risk.
Failure to Include Bed Rails in Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, specifically regarding the use of bed rails. Resident #226, a male with severe vision impairment and hemiplegia following a stroke, was admitted without the use of bed rails being included in his care plan. Despite being informed of the potential dangers of bed rails, the resident's care plan did not address their use, and observations confirmed the bed rails were consistently in use without being documented in the care plan. Similarly, Resident #221, a female with muscle wasting and atrophy, was admitted with a baseline care plan that did not include the use of bed rails, despite her cognitive impairments. Observations showed that the bed rails were always up, and the resident used them for repositioning, yet this was not reflected in her care plan. The resident was aware of the bed rails but did not know how to lower them, indicating a lack of comprehensive planning and staff awareness. Resident #320, a male with dementia and Parkinson's disease, also had a care plan that failed to include the use of bed rails. Although there were orders for mobility aids, the care plan did not document the use of bed rails, which were observed in the upright position. The Director of Nursing acknowledged that bed rails were used as enablers and required physician orders, consent, and inclusion in the care plan, which was not done for these residents. This oversight could lead to residents not receiving necessary care or services tailored to their specific needs.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for three residents, leading to a deficiency in their care. For Resident #226, the facility did not attempt to use appropriate alternatives before installing bed rails and failed to assess the resident for the risk of entrapment. Despite the resident's severe vision impairment and paralysis, the necessary documentation indicating attempts to use alternatives was left blank. Observations showed the resident with bed rails up, although he had never used them. Similarly, for Resident #221, the facility did not explore alternatives before installing bed rails and did not assess the risk of entrapment. The resident, who had muscle wasting and cognitive impairments, was observed with bed rails up and was unaware of how to lower them. The Director of Nursing (DON) confirmed that bed rails were used as enablers and required physician orders, consent, and care planning, which were not adequately documented. For Resident #320, the facility also failed to conduct a proper assessment for the use of bed rails. The resident, diagnosed with dementia and Parkinson's disease, had no documented evaluation for the use of bed rails. Observations revealed the resident with bed rails up and side bolsters on the mattress, yet the baseline care plan did not include the use of bed rails. The facility's policy on mobility bars was not followed, as the necessary informed consent and assessment were not completed.
Food Storage and Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. An opened bag of shredded cheddar cheese was found in the reach-in cooler, stored in a clear, gallon-sized storage bag with a zipper-seal that was left open. This oversight was acknowledged by the dietary staff (DS), who confirmed that all food should be properly labeled, dated, and stored in sealed containers to prevent cross-contamination and spoilage. Additionally, a storage bag containing cooked pork was found unsealed and without a use-by date, contrary to the facility's policy of using leftovers within seven days. The DS confirmed that all dietary staff were trained to store leftover food in sealed bags or containers with appropriate labeling and dating. Furthermore, a mop was improperly stored in the equipment storage closet with the mop head on the ground, preventing it from air drying. The DS acknowledged that the mop should have been stored on a hook to allow for proper drying. The facility's dietary policies, based on the Texas Food Establishment Rules (TFER) and the U.S. Public Health Service Food Code, were not followed in these instances, which could potentially place residents at risk for foodborne illness.
Failure to Properly Document Resident's DNR Order
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order was properly included and completed in the medical record. The resident, a male with dementia, Parkinson's disease, and adult failure to thrive, was admitted to the facility with a DNR status. However, the DNR document in the resident's file was incomplete, lacking the necessary witness or responsible party (RP) signature at the bottom, despite having two physician signatures. Interviews revealed that the social worker (SW) was unaware of any pending DNRs and was uncertain about the resident's DNR status or its location, as they had just started at the facility. The Director of Nursing (DON) acknowledged that the clinical staff was assisting the new SW with DNR paperwork and admitted that if the resident had coded, CPR would have been performed due to the delay in locating the DNR. The DON also incorrectly stated that the RP's signature was unnecessary because of the two provider signatures. Further investigation showed that the resident's RP did not complete a DNR form and expressed concern about a forged signature on the document. The RP confirmed a desire for a DNR but stated that the facility did not request any paperwork, and discussions about the DNR only occurred with hospital staff before the resident's admission. The facility's policy on advance directives was not followed, as it required providing written information about advance directives and documenting the resident's or RP's wishes in the health record.
Inadequate Catheter Care Leads to Deficiencies
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to potential risks of urinary tract infections. Resident #77, a male with severe cognitive impairment and an indwelling urinary catheter, was observed with a catheter bag filled with approximately 1,200 ml of urine. During catheter care, the CNA placed the catheter bag on the bed, which could lead to backflow and potential infection. The CNA acknowledged the oversight and the Director of Nursing confirmed the risk of infection due to improper handling of the catheter bag. Resident #312, a male with an indwelling urinary catheter, was observed receiving inadequate catheter and perineal care. The CNA cleaned the resident's penis in the wrong direction, failed to clean the scrotum and under it, and did not fully separate the buttocks to clean between the folds. The resident had purulent discharge from the urethra, and the CNA admitted to not being familiar with the resident's care needs. The DON confirmed that improper cleaning could lead to infection, and the resident had been diagnosed with a UTI and required IV antibiotics. Both CNAs involved had completed training and competency reviews for catheter care, yet failed to adhere to proper procedures. The facility's policy required catheter care to promote hygiene and reduce infection risk, but these standards were not met in the observed cases, leading to deficiencies in care for the residents.
Failure in Dialysis Communication and Coordination
Penalty
Summary
The facility failed to ensure proper communication, coordination, and collaboration with the dialysis facility for two residents requiring dialysis services. For Resident #226, the facility did not maintain complete and accurate documentation on the Renal Dialysis Communication Forms. Specifically, the form dated 9/23/24 was missing the dialysis staff's signature, and the form dated 9/26/24 contained a request for information regarding the resident's elevated blood pressure, which was not confirmed as received by the dialysis clinic. Interviews with the ADON and DON revealed that the forms were not checked for completeness in a timely manner, and there was uncertainty about whether the necessary information had been communicated to the dialysis clinic. For Resident #75, the facility also failed to complete the Renal Dialysis Communication Forms accurately. The form for 9/17/24 was missing entirely, and the forms for 9/24/24 and 9/26/24 were not completed upon the resident's return from dialysis. Additionally, it was noted that the resident missed dialysis on 9/17/24, which was documented by LVN E. The ADON acknowledged the oversight in reviewing the forms and confirmed that the resident did not attend dialysis on the specified date. The facility's policy and procedure for dialysis care, dated 3/2009, emphasized the importance of ongoing communication and collaboration with the dialysis facility. However, the facility did not adhere to these standards, resulting in incomplete documentation and potential lapses in communication regarding the residents' dialysis care. This deficiency could affect the residents receiving dialysis treatments, placing them at risk for complications and inadequate care.
Failure to Coordinate Hospice Care and Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services, specifically for one resident reviewed. This deficiency was identified through interviews and record reviews, which revealed that the facility did not ensure the availability of the most recent plan of care, DNR, and hospice physician orders for a resident. The absence of these critical documents in the resident's hospice binder and electronic medical record indicated a lack of proper documentation, coordination of care, and communication of resident needs. The report highlights that the facility's Director of Nursing (DON) and Social Worker (SW) were unaware of the location of the DNR and other hospice-related documents, which could have led to inadequate end-of-life care. The DON admitted that if an emergency had occurred, the resident might have received CPR due to the delay in locating the DNR. The facility's policy on end-of-life care emphasizes the importance of individualized care plans and collaboration with hospice services, which was not adhered to in this case.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents with indwelling urinary catheters. In the first incident, a CNA did not perform appropriate hand hygiene after removing gloves during catheter care for a resident. This resident, who was severely cognitively impaired and had a history of urinary tract issues, was at risk of infection due to the CNA's failure to sanitize or wash hands after glove removal, which was acknowledged by both the CNA and the Director of Nursing (DON) as a breach of proper infection control practices. In the second incident, another resident's catheter tubing was observed touching the floor, and staff failed to use enhanced barrier precautions (EBP) when providing care. This resident, who had recently been admitted and had undergone surgical amputation, was on EBP due to the presence of an indwelling urinary catheter. Despite this, staff did not wear gowns while repositioning the resident, which involved high-contact activities that required such precautions according to the facility's policy. The DON confirmed that the catheter tubing should not touch the floor and that staff should wear gowns during high-contact care activities. Both incidents highlight lapses in adherence to infection control protocols, specifically regarding hand hygiene and the use of personal protective equipment (PPE) during care of residents with indwelling medical devices. These deficiencies were identified through observations, interviews, and record reviews, and were acknowledged by the facility's DON as practices that could increase the risk of infection among residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mccullough Hall Nursing Center Inc | 0.8 mi | — | 0 | 0 |
| Avir At San Antonio | 0.8 mi | — | 3 | 0 |
| Hunters Pond Rehabilitation And Healthcare | 1.8 mi | — | 1 | 0 |
| San Jose Nursing Center | 1.9 mi | — | 0 | 0 |
| Windsor Mission Oaks | 3.8 mi | — | 0 | 0 |
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