Deficiency Records for Legend Oaks Healthcare and Rehabilitation-Kyle
Updated as of March 01, 2024
A list of the most recent deficiencies for Legend Oaks Healthcare and Rehabilitation-Kyle. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-21 | 2024-01-26 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-08-10 | 2023-08-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-10 | 2023-08-22 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-08-10 | 2023-08-22 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-30 | 2023-07-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-30 | 2023-07-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-30 | 2023-07-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-30 | 2023-07-28 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-06-30 | 2023-07-28 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-06-30 | 2023-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-30 | 2023-07-28 | N |
| Dispose of garbage and refuse properly. | Health | 2023-06-30 | 2023-07-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-06-28 | 2023-06-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-28 | 2023-06-29 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-06-13 | 2023-06-22 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-06-13 | 2023-06-22 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-06-13 | 2023-06-22 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-12-08 | 2022-12-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-21 | 2022-12-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-23 | 2022-04-06 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-27 | 2021-08-13 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-11 | 2019-10-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-11 | 2019-10-28 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-10-11 | 2019-10-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-11 | 2019-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-11 | 2019-10-28 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-10-09 | 2019-10-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-09 | 2019-10-10 | N |
