F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to immediately notify the resident's physician when there was
a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for
resident rights.
The facility failed to ensure Resident #1's NP was notified that she began consistently refusing and/or
spitting out her medications in the middle of December 2024.
This failure placed residents at risk of medical diagnoses not getting treated and a decreased quality of life.
Findings included:
Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the
facility on [DATE] with diagnoses including essential hypertension (high blood pressure), dysphagia
(difficulty swallowing), type II diabetes, and dementia.
Review of Resident #1's quarterly MDS assessment, dated 10/25/24, reflected a BIMS score of 1,
indicating she had severe cognitive impairment. Section K (Swallowing/Nutritional Status) reflected she had
a history of coughing or choking during meals or when swallowing medications.
Review of Resident #1's quarterly care plan, dated 10/28/24, reflected no focus or interventions related to
refusing and/or spitting out her medications.
Review of Resident #1's MARs, December of 2024 and January of 2025, reflected around 12/14/24, her
medication administrations were being marked either 1 or 5 on a consistent basis. 1 indicated the drug was
refused, and 5 indicated she spit the medication out. From 12/14/24 - 12/31/24, there were three instances
she refused her medications and seven where she spit them out. From 01/01/25 - 01/12/25, there were
seven instances where she refused her medications and five where she spit them out.
During an interview on 01/17/25 at 11:02 AM, Resident #1's NP stated she last saw her on 12/20/24. She
stated she was not made aware of Resident #1 refusing and/or spitting out her medications. She stated she
would expect to be notified in that case. She stated she would expect for the nurses to document the
refusals, keep trying, or try other interventions.
During an interview on 01/17/25 at 1:02 PM, LVN A stated Resident #1 had been refusing (by not opening
her mouth) or spitting out the pudding (with her crushed medications) for at least a month. He
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
676238
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676238
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - North
11020 Dessau Rd
Austin, TX 78754
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
stated the medication aides would tell him when that would happen, and he would attempt to get her to
swallow as much as he could. He stated he did not specifically tell the NP about that but believed she knew.
During an interview on 01/17/25 at 1:15 PM, LVN B stated Resident #1 had, for a while, been refusing or
spitting out her medications. She stated she would keep her at the nursing station and would encourage
her. She stated sometimes she would gradually swallow the pudding. She stated she thought the NP was
aware of that behavior, but could not remember if she had told her.
During an interview on 01/17/25 at 3:05 PM, the DON stated the NP should be notified by the nurse if a
resident had multiple refusals of their medication. She stated it was important for the NP to be aware so
they could discuss and determine what the next steps could be or what needed to be done. She stated a
negative outcome of the NP not being involved was everyone not being involved in the residents' care .
Review of the facility's Notification of Physician Policy, revised 08/2007, reflected the following:
1. The Nurse Supervisor will notify the resident's attending physician when:
.
D. The resident repeatedly refuses treatment or medications (i.e. two (2) or more consecutive times.
Review of the facility's Administration of Medication Policy, revised 06/2022, reflected the following:
It is the policy of this facility that medications shall be administered as prescribed by the attending
physician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676238
If continuation sheet
Page 2 of 2
