Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 - West S during CMS and state inspections, most recent first.
A resident with BPH, neurogenic bladder, and an indwelling urinary catheter received improper catheter care when a CNA grasped the resident’s genitals instead of the catheter tubing and wiped along the tubing in a way that made it taut, repeating this several times. The resident, who had moderately impaired cognition, did not voice pain during the procedure. Facility policy and staff training required grasping and securing the catheter tubing and cleaning downward from the meatus to prevent migration, friction, or tension, and competency records showed the CNA had been validated in this skill.
A resident with a suprapubic catheter and moderately impaired cognition was care-planned for Enhanced Barrier Precautions (EBP), with signage on the door and facility policy requiring gown and gloves for high-contact care. During observed incontinence care, a CNA applied a disposable brief without wearing a gown, despite having received infection prevention training. In interviews, the CNA acknowledged she should have worn a gown and the ADON/Infection Preventionist confirmed that gowns and gloves were required for close-contact care under EBP, indicating the facility did not follow its own IPCP and EBP policy.
A CNA failed to perform hand hygiene and change gloves between cleaning a resident's vaginal and rectal areas during incontinence care, resulting in a break in infection control procedures. The resident had significant cognitive and physical impairments and required frequent assistance with incontinence care. Facility policy and the CNA's training required proper hand hygiene and glove changes, but these were not followed during the observed care.
The facility did not distribute mail received on Saturdays to residents, leading to a delay in mail delivery. Residents expressed dissatisfaction with this practice, which was confirmed by interviews with staff, including the ADON and Weekend Receptionist. The facility's policy indicated mail should be delivered on the day of receipt or the next business day.
A resident with heart failure, type II diabetes, and dementia was provided a personal locked box for his money, but the facility failed to update his care plan to reflect this. The MDS nurse was unaware of the locked box, leading to a lack of communication in the care plan. The DON acknowledged the oversight, which could result in staff providing incorrect care.
The facility failed to ensure adequate supervision for two residents with a history of suicidal ideations and Major Depression. One resident attempted suicide by ingesting mouthwash, while another had potentially harmful items in her room. Staff were not aware of the residents' suicidal histories, leading to a lack of proper monitoring and supervision.
A resident with a history of major depression and suicidal ideation attempted suicide by ingesting mouthwash. The incident was discovered by a CNA and reported to the RN, who notified the MD, NP, family member, EMS, and law enforcement. Despite the severity of the incident, the facility did not report it to the Health and Human Services Commission (HHSC) within the mandated two-hour window, as required by their policies and state regulations.
Improper Catheter Care Technique Resulting in Tension on Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate catheter care for a resident who was incontinent of bladder and had an indwelling urinary catheter. The resident was an elderly male with benign prostatic hyperplasia and neurogenic bladder, with a moderately impaired cognitive status (BIMS score of 09), and had an indwelling catheter in place per his MDS and care plan. Facility policy on indwelling urinary catheter care directed staff to clean the catheter in a downward motion from the urinary meatus toward the collection bag and to secure the tubing as needed to prevent migration, friction, or tension. During an observed episode of routine catheter care, CNA A grasped the base of the resident’s genitals instead of the catheter tubing and wiped along the catheter tubing away from the resident’s body, causing the catheter tubing to become taut. She repeated this action three times. The resident did not express pain or discomfort and stated he was okay. In subsequent interviews, CNA A and the ADON both stated that staff were trained to grasp the catheter tubing before wiping, and both identified that not securing the tube while cleaning could lead to accidental removal, trauma to the catheter site, or displacement. The facility’s competency checklist documented that CNA A had been validated as competent in male perineal care with a catheter, indicating that the observed technique did not follow her training or facility policy regarding prevention of catheter tension.
Failure to Follow Enhanced Barrier Precautions During Care of Catheterized Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) for a resident with an indwelling suprapubic catheter. The resident was an older male with benign prostatic hyperplasia and lower urinary tract symptoms, admitted with a diagnosis requiring an indwelling catheter, and had a BIMS score of 07 indicating moderately impaired cognition. The resident’s MDS documented the presence of an indwelling catheter, and the care plan reflected that the resident had a suprapubic catheter and was to be cared for under EBP beginning on 9/17/2025. A sign on the resident’s exterior door indicated that EBP were in place. During an observation, a CNA was seen applying a clean disposable brief to this resident without wearing a disposable gown, despite the resident being on EBP. The CNA later stated in an interview that she had received infection prevention training, acknowledged she should have worn a disposable gown while applying the brief, and attributed the lapse to being nervous, noting the potential risk was infection. The ADON, who served as the facility’s Infection Preventionist, confirmed in an interview that staff were required to wear disposable gowns and gloves during close-contact care for residents on EBP and that the CNA should have worn a gown during this care activity. The facility’s written policy on IPCP Standard and Transmission-Based Precautions, revised in 3/2024, specified that EBP expand the use of PPE through the use of gown and gloves during high-contact resident care activities, which was not followed in this instance.
Failure to Follow Hand Hygiene and Glove Change Protocol During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinent/peri care for a resident. The CNA washed her hands initially, but after using the bed remote, she donned gloves without performing hand hygiene. During the care, the CNA used the same pair of gloves to clean both the resident's vaginal area and then the rectal/buttock area, without changing gloves or performing hand hygiene between these tasks. The CNA acknowledged during an interview that she should have changed gloves and performed hand hygiene between these steps, recognizing this as a break in infection control and cross-contamination. The resident involved was a female with multiple diagnoses, including encephalopathy, memory deficit, Parkinson's disease, muscle wasting, lack of coordination, and urinary retention. She was moderately cognitively impaired, required substantial assistance with mobility, and was frequently incontinent of bladder and always incontinent of bowel. Facility policy and the CNA's competency checklist both required proper hand hygiene and glove changes during incontinence care, but these procedures were not followed during the observed incident.
Failure to Distribute Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents' right to receive mail in a timely manner, as mail received on Saturdays was not distributed to residents. During a confidential group meeting, residents expressed that they did not receive mail on Saturdays and felt this practice was disrespectful. Interviews with the Assistant Director of Nursing (ADON), Assistant Business Office Manager (ABOM), and Weekend Receptionist revealed that mail was left for sorting and distribution on Mondays unless residents specifically requested their mail. The Director of Nursing (DON) acknowledged that residents should receive their mail on Saturdays. The facility's undated policy stated that the business office would deliver mail to residents' rooms on the day of delivery or the next business day.
Failure to Update Resident Care Plan for Personal Lock Box
Penalty
Summary
The facility failed to review and revise the care plan for a resident, identified as Resident #28, after a comprehensive assessment. Resident #28, a 65-year-old male with diagnoses including heart failure, type II diabetes, and unspecified dementia, was admitted to the facility with an intact cognitive status as indicated by a BIMS score of 15. Despite being provided with a personal locked box for his money, this information was not updated in his care plan. The MDS nurse admitted to not being aware of the locked box and therefore did not update the care plan accordingly. The Director of Nursing (DON) confirmed that the MDS nurse should have updated the care plan following the quarterly MDS assessment, as the resident had received the locked box prior to this assessment. The failure to update the care plan could lead to staff being unaware of the resident's use of a personal lock box, potentially resulting in incorrect care. The facility's policy requires the interdisciplinary team to develop a comprehensive, person-centered care plan for each resident, which includes measurable objectives and time frames.
Inadequate Supervision for Residents with Suicidal Ideations
Penalty
Summary
The facility failed to ensure adequate supervision for two residents with a history of suicidal ideations and Major Depression. Resident #1, who had a history of suicidal ideations and a diagnosis of Major Depression, attempted suicide by ingesting mouthwash. The resident was found slumped over in his wheelchair and was subsequently sent to the ER and placed under emergency detention. The facility did not have adequate measures in place to monitor items brought into the resident's room, and staff were not aware of the resident's suicidal history, leading to a lack of proper supervision and monitoring for harmful items. Resident #2, also diagnosed with Major Depression, had items in her room that could pose a danger of self-harm, including a mouthwash bottle and shampoo bottles. The resident expressed feelings of sadness and occasional thoughts of self-harm, but there was no plan in place to monitor or remove potentially harmful items from her room. The facility staff, including CNAs and nurses, were not aware of the resident's suicidal ideation history and did not conduct regular checks for harmful items. The facility's failure to implement adequate supervision and monitoring for residents with a history of suicidal ideations and Major Depression resulted in an Immediate Jeopardy situation. The facility did not have a policy in place to inventory items brought in from the outside for residents at risk of self-harm, and staff were not adequately trained to identify and remove potentially harmful items. This lack of supervision and monitoring could lead to injury, harm, or death for residents with suicidal tendencies.
Failure to Report Suicide Attempt
Penalty
Summary
The facility failed to report an allegation of a suicide attempt by a resident to the State Survey Agency within the required timeframe. On 03/21/24, a resident with a history of suicidal ideation and depression attempted suicide by ingesting mouthwash. The incident was discovered by a CNA and reported to the RN, who then notified the MD, NP, family member, EMS, and law enforcement. Despite the severity of the incident, the facility did not report it to the Health and Human Services Commission (HHSC) within the mandated two-hour window for serious bodily injury or abuse allegations. The resident involved had a history of major depression and previous suicide attempts, including an incident where he tried to smother himself and lick deodorant. On the day of the incident, the resident was found shaking uncontrollably and admitted to attempting suicide by drinking mouthwash. EMS and law enforcement were called, and the resident was subsequently admitted to a psychiatric hospital. The facility's records and interviews with staff confirmed that the incident was not reported to HHSC as required by the facility's own policies and state regulations. Interviews with the Director of Nursing (DON) and the Administrator revealed that they did not believe the incident warranted reporting to HHSC, as they did not consider it neglect. The DON and Administrator cited a Provider Letter and concluded that the suicide attempt was due to family dynamics rather than neglect. This decision was made despite the facility's policies on abuse, neglect, and suicide threats, which mandate immediate reporting of such incidents to the appropriate authorities.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| The Mission At Blue Skies Of Texas East | 1.2 mi | — | 0 | 0 |
| Lakeside Nursing And Rehabilitation Center | 2.3 mi | — | 0 | 0 |
| Westover Hills Rehabilitation And Healthcare | 3.7 mi | — | 2 | 0 |
| Windemere At Westover Hills | 4.2 mi | — | 6 | 0 |
| Harbor Valley Health And Rehabilitation | 4.4 mi | — | 18 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.