Deficiency Records for Legend Oaks Healthcare and Rehabilitation-Kyle

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Updated as of May 01, 2024

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Deficiency Records for Legend Oaks Healthcare and Rehabilitation-Kyle

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.

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

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