Legend Oaks Healthcare and Rehabilitation - Ennis

In the surveyor’s words

From the most serious findings on record at Legend Oaks Healthcare and Rehabilitation - Ennis, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 17, 2023

  Based 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 three residents reviewed for accidents and hazards, in that: The facility failed on [DATE] to ensure Resident #1 remained free of hazards and had adequate supervision in that she suffered a fall that resulted in a pool of blood around her head, a skin tear to her left elbow, and bruises on all extremities which lead to her subsequent hospitalization with 3 fractured ribs on the left (8th, 9th, and 10th rib). An immediate jeopardy existed from [DATE] - [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Sep 9, 2021

  Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food was properly stored in the facility's refrigerator and freezer. 2. The facility failed to ensure expired foods were discarded. These failures could place all residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on [DATE] at 9:30 AM revealed: - 1 box dated [DATE] contained 18 cantaloupes with fuzzy white and black spots; and - 1 bag dated [DATE] contained 7 cabbages with fuzzy white and black spots; Observation of the facility's freezer on [DATE] at 9:55 AM… […]

• No harm, potential for more than minimal, patternF677May 7, 2026

  Based on observation, interview and record review, the facility failed to ensure that 3 residents (Resident's #34, #61, and #64) out of 6 residents reviewed for activities of daily living received care and services for nail care. The facility failed to ensure that Residents #34, #61, and #64's fingernails were cleaned. This failure placed residents at risk for not receiving adequate care and services to prevent infection, injury, and diminished quality of life.Findings include: Record review of Resident #34's face sheet dated 05/06/26 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: metabolic encephalopathy (a broad term for brain dysfunction caused by non-traumatic, systemic issues like chemical imbalances, organ failure, or infections,… […]

• No harm, potential for more than minimal, patternF689Feb 27, 2025

  Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents for four of four residents (Residents #12, #19, #58, and #171) reviewed for accidents and hazards. The facility failed to properly maintain wheelchairs and anti-pressure cushions for Residents #12, #19, #58, and #171 . These failures could place residents at risk for equipment that is in unsafe operating condition, which could cause injury. Findings included: 1. Record review of Resident #12's quarterly MDS assessment, dated 02/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF689Jan 11, 2024

  Based on observation, interview and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for five (Residents #8, #28, #33, #35, and #47) of 18 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #8, #28, #33, #35, and #47. These failures could place residents at risk for equipment that is in unsafe operating condition, that could cause injury. Findings included: Review of Resident #8's quarterly MDS assessment, dated 10/18/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of CVA (Stroke) and hemiplegia (partial weakness on same side of the body) and hemiparesis (partial weakness on one side of the body) effecting the nondominated side. […]