Legend Oaks Healthcare and Rehabilitation - Waxaha

In the surveyor’s words

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

• Immediate jeopardy, patternF656Jul 24, 2022

  Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to develop a comprehensive fall prevention care plan that addressed resident-specific risk factors for falls for 2 (Resident #11 and Resident #20) of 4 sampled residents reviewed for falls. The facility also failed to ensure comprehensive care plans addressed the necessary care and monitoring related to: - chronic diarrhea for 1 (Resident #83) of 1 sampled resident reviewed for constipation/diarrhea. - pre and post-dialysis care for 1 (Resident #48) of 1 sampled resident reviewed for dialysis. - rehabilitation (rehab) services for 1 (Resident #90) of 2 sampled residents reviewed for rehab. - wound care for 1 (Resident #76) of 4 sampled residents reviewed for wound care. […]

• Immediate jeopardy, patternF689Jul 24, 2022

  Based on observations, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent accidents for 2 (Resident #11 and Resident #20) of 4 sampled residents reviewed for falls. Specifically, the facility failed to: - investigate falls to determine causal factors and develop and implement fall prevention interventions that were specific, resident-appropriate, and based on causal factors for Resident #11 and Resident #20. - consistently implement planned interventions to prevent further falls for Resident #11 and Resident #20. […]

• Immediate jeopardy, isolatedF689Mar 7, 2024

  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 five residents reviewed for accidents and hazards, in that: The facility failed to assist and monitor Resident #1 during meal service on 02/20/24 when she was served dinner despite a hospice order dated 02/11/24 stating that she should be assisted with meals and not left alone with food, and Resident #1 choked and was subsequently sent to the ER where she was diagnosed with aspiration pneumonia and remained hospitalized until 02/25/24. An Immediate Jeopardy (IJ) was identified on 03/05/24. […]

• Immediate jeopardy, isolatedF689Feb 7, 2024

  Based on observation, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 18 Residents (Resident #1 and Resident #2) reviewed for accidents and hazards. 1. The facility failed to ensure Resident #1 received microwaved food, from an outside source, at a temperature for safe elderly consumption which resulted in a second-degree burn. 2. The facility failed to ensure Resident # 2 had total assistance while consuming a cup of hot coffee resulting in medical attention for skin irritation. On 2-5-2024 at 7:54 PM an Immediate Jeopardy (IJ) was identified. […]

• Actual harm, isolatedF684Nov 15, 2024

  Based on observations, interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 9 Residents (Resident #162) reviewed for quality of care. The facility failed to ensure Resident #162 made follow up appointment with a wound care specialist. This failure placed residents at risk of condition exacerbation, psychosocial harm, and infection. Findings included: Record review of an intake, dated 11/7/2024 at 8:21 AM, reflected a complaint made by a responsible party on behalf of Resident #162. The intake alleged on 11/2/2024 a staff attempted to transfer Resident #162 from her wheelchair to her bed. […]