Legend Oaks Healthcare and Rehabilitation - Fort W

In the surveyor’s words

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

• Immediate jeopardy, patternF760Jun 13, 2026

  Based on observation, interview and record review, the facility failed to ensure each resident was free of any significant medication errors for 1 of 6 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1, who was diagnosed with Stage 4 renal carcinoma (kidney cancer), was administered his physician ordered oral chemotherapy medication, axitinib 3 mg bid, to treat his advanced kidney cancer. On 05/27/26 a computed tomography (CT) scan showed a 2 mm increase in the mass on Resident #1's right kidney. An Immediate Jeopardy (IJ) was identified on 06/12/26 at 4:16 p.m. and an IJ Template was provided to the Administrator at 4:50 p.m. […]

• Immediate jeopardy, isolatedF689Sep 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1, who was a high risk for elopement for which he wore a WanderGuard device, was provided with adequate supervision to prevent him from exiting the building on 07/28/25. Despite the WanderGuard alarm sounding, RN A turned the alarm off without immediately going outside to determine if there was a resident elopement. The resident was found approximately nine hours after he went missing. […]

• Immediate jeopardy, isolatedF689Oct 8, 2024

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #2) reviewed for elopement. The facility failed to provide adequate supervision to Resident #2, who was aphasic and had right-sided hemiplegia, when the resident left the faciity on [DATE] without staff knowledge and made it approximately 1.5 miles from the facility with the assistance of a bystander. The resident was out of the facility for approximately two hours without staff knowledge, and he was located by his family who had placed a tracking device on his shoe. The non-compliance was identified as past non-compliance. The IJ began 09/15/24 and ended on 09/23/24. […]

• Immediate jeopardy, isolatedF689May 25, 2023

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for supervision. The facility failed to ensure a resident with known wandering behaviors was provided with adequate supervision to prevent her from eloping and subsequently falling and sustaining a left hip fracture. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 05/12/23 and ended on 05/13/23. The facility had corrected the noncompliance before the survey began. […]

• Actual harm, patternF689Apr 17, 2026

  Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents.The facility failed to address the root cause of Resident #1's multiple falls, failed to implement therapy recommendations, and failed to implement interventions to prevent the resident from falling from his wheelchair from November 2025 to February 2026. […]