Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure an allegation of neglect was reported immediately,
but not later than 2 hours after the allegation was made, when the events that caused the allegation
involved neglect for 1 of 8 Residents (Resident #48) whose records were reviewed for neglect.
The ADM failed to report an allegation of neglect to the State Survey Agency within 2 hours after Resident
#48 fell backwards in his wheelchair during transport to Dialysis.
This deficient practice could affect any resident and contribute to further resident neglect.
The findings were:
Review of Resident 48's face sheet, dated 1/10/24, revealed he was initially admitted to the facility on
[DATE] with diagnoses including End Stage Renal Disease (kidney failure) and Type 2 Diabetes Mellitus
with Diabetic Peripheral Angiopathy (Narrowing of arteries which results in reduced blood flow to head,
arms, stomach and legs) without Gangrene.
Review of Resident #48's admission MDS assessment, dated 10/27/23, revealed his BIMS score was 14
reflective of minimal cognitive impairment and he received Dialysis.
Review of the facility PIR, dated 1/10/24, involving Resident #48 revealed the incident date was 1/3/24 at
2:12 PM. The incident narrative read Resident #48 rolled backward in the wheelchair, fell in the
transportation van and hit the back of his head. He sustained a 1.5 cm laceration on the back of his head.
EMS and the fire department were dispatched out. Resident #48 was taken to the hospital.
Review of an incident summary written by the Director of Operations for the van company, dated 1/3/24,
revealed it was their policy to secure the wheelchair to the floor with four ratchet straps. The back two were
crossed in a 'fashion and the front two were attached to the front of the frame near the wheel as to not
obstruct the patient's leg area. The straps were tightened and tested by moving the wheelchair side to side.
There should be minimal movement.
Review of a statement taken from the van driver on 1/3/24 revealed he tied the front and back straps to the
back wheels. He attempted to lift the wheelchair to an upright position and was unable to do so. He called
dispatch for assistance.
Review of an email sent by the ADM to HHSC revealed the incident was reported on 1/3/24 at 7:46 PM.
(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 9
Event ID:
676392
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
676392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br
2468 Fm 1101
New Braunfels, TX 78130
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 1/25/24 at 11:30 AM with the ADM revealed he was the abuse coordinator and responsible for
reporting and investigating all allegations of abuse and neglect. He stated the allegation of resident neglect
involving Resident #48 was reported late and not within 2 hours as required per regulation. He stated the
incident took place across the street and he learned about the incident within minutes. The ADM confirmed
per the email he sent to HHSC that he reported the allegation at 7:46 PM. The ADM stated it was important
to follow facility policy to ensure the resident's safety and to prevent further incidents of abuse and neglect.
Review of a facility policy, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment,
revised on 1.2022, read: Procedure: In response to allegations of abuse, neglect, exploitation, or
mistreatment, the facility will: Ensure that all alleged violations involving abuse, neglect, exploitation or
mistreatment, including injuries of unknown source and misappropriation of resident property, are reported
immediately but: Not later than two (2) hours after the allegation is made if the events that cause the
allegation involves abuse or results in serious bodily injury. Ensure that all alleged violations involving
abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of
resident property, are reported to: The Administrator of the Facility, The State Survey Agency.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676392
If continuation sheet
Page 2 of 9
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
676392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br
2468 Fm 1101
New Braunfels, TX 78130
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman
of the transfer or discharge and the reasons for the transfer or discharge in writing for 1 of 3 residents
(Residents # 103) resident reviewed for transfer and discharge.
The facility initiated a discharge for Resident #103 due to a change of condition and did not notify the State
Long-Term Care Ombudsman by phone or in writing.
This failure could place residents at risk of improper discharge planning and diminished quality of life.
Findings included:
Record review of Resident # 103 's EMR and face sheet, dated 01/26/24, revealed an admission date of
10/18/23 and a discharged date 10/30/23 to hospital with diagnoses that included: blood clog (primary),
HTN, and heart failure. The resident was a female, age [AGE]. The RP was listed as the resident.
Closed record review of Resident# 103's Care Plan, revealed, the goals and interventions included:
Anticoagulant therapy with interventions of labs as ordered, report abnormal findings to the MD, and
monitor and report signs and symptoms of anticoagulant complications.
Closed record review of Resident#103's MAR dated October 2023, revealed, resident received coumadin 5
mgs daily every day (10/18/23-10/30/23) Give 1 tablet by mouth in the evening for A Fib (irregular heart
rate).
Closed record review of Resident#103's Nurse Note dated 10/30/23 authored by LVN A, read . resident's
coumadin was on hold due to elevated INR (International Normalized ratio) from last week. Received new
INR result for today of 23 [high INR (blood clog]. Reported to NP , new order to send to ER.
Closed record review of various Nurse Notes dated 10/30/23 did not revealed no note revealing the
Ombudsman office was notified of the hospital transfer on 10/10/23 or in the months of October 2023 to
January 2024.
Closed record review of Resident#103's lab, dated, 10/25/23 revealed: INR was 24.20 (high).
Closed record review of Resident #103's discharge MDS dated [DATE], revealed the date Resident #103
was sent to the hospital for assessment, in section A0310, Type of Assessment, it was marked F. 10.
Discharge assessment - return not anticipated.
During an interview on 1/26/24 at 3:00 PM, the MDS Nurse stated that she was not aware of the
requirement to send a written notice to the Ombudsman's office when a resident was transferred or
discharged and returned to the facility was not anticipated.
During an interview on 1/26/24 at 3:05 PM, the DON stated she was aware of the requirement to send a
written notice to the Ombudsman at least after 30 days of discharge or transfer. The DON stated
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676392
If continuation sheet
Page 3 of 9
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
676392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br
2468 Fm 1101
New Braunfels, TX 78130
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 0623
Level of Harm - Minimal harm
or potential for actual harm
the former social worker may have overlooked sending the notice for Resident #103. The DON stated she
was responsible to check with the MDS Nurse or the Social Worker that the written notice of transfer
involving Resident #103 was sent to the Ombudsman Office. The DON stated the resident was not
expected to return to the facility because of the change of condition; but the resident could return to the
facility.
Residents Affected - Few
During an interview on 01/26/24 at 3:09 PM, the SW stated, she was aware of the requirement of a written
notice to be sent to the resident or RP and the Ombudsman's office involving a transfer or discharge. The
SW stated she was not present in October 2023 (her hire date January 8, 2024) and had no explanation
why the written notice was not sent to the Ombudsman by the previous social worker
During a telephone interview on 01/26/24 at 3:12 PM, the Ombudsman stated she did not received the
required 30 notice of transfer that involved Resident#103 in the month of October 2023 or any time
thereafter.
Record review of facility's Criteria for Transfer and discharge date d revised 01/2022 read: .ensure the
transfer or discharge is documented in the resident's medical record and appropriate information is
communicated to the receiving health care institution or provider. The policy reflected that one of the
regulatory references was F623 Notice Requirements Before Transfer/Discharge.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676392
If continuation sheet
Page 4 of 9
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
676392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br
2468 Fm 1101
New Braunfels, TX 78130
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 0636
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every
12 months.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to conduct a periodic comprehensive assessment
of each resident's functional capacity for 1 of 8 Residents (Resident #42) whose records were reviewed for
assessments.
MDS staff failed to assess Resident #42 for activity preferences on her annual MDS.
This deficient practice could affect any resident and could result in the assessment being incomplete and or
not reflecting a complete pictures of the resident's activity preferences.
The findings were:
Review of Resident #42's annual MDS, dated [DATE], revealed she was admitted to the facility on [DATE]
with diagnoses including unspecified Dementia, Anxiety Disorder and unspecified protein calorie
malnutrition. Further review revealed the assessment did not reflect her preferences for activities. The MDS
read not assessed.
Review of Resident #42's Care Plan revised on 11/2/23 revealed she had the potential for social isolation
related to Dementia. Some of the interventions was for staff to encourage Resident #42 to participate in
watching TV, participate in outdoor activities and participate in religious activities.
Observation and interview on 1/25/24 at 1:30 PM revealed Resident #42 lying in bed with her head of the
bed in about a 45-degree angle. Resident #42's family member was visiting. The TV was on. Resident #42's
family member stated Resident #42 stayed in her room the majority of the time. She liked to watch TV. She
stated therapy would also walk Resident #42 to the lobby where she would sit and look out until she was
ready to return to her room. Resident #42 also enjoyed having her hair done and going outside when it was
warm. Resident #42's family member stated Resident #42 enjoyed participating in activities but not over
stimulating activities because she had anxiety.
Interview on 01/27/24 at 12:03 PM with the MDS Coordinator, LVN B revealed Resident #42 was not
assessed for activity preferences during the annual MDS assessment, dated 11/2/23. LVN B stated the
assessment was the most recent annual assessment and did not know why the section was not completed.
LVN B stated it should have been because resident's preferences would change at times due to their
current state of mind. She stated it was important to include activities the Resident enjoyed for their
participation in activities that enhanced their quality of life. LVN B further stated they used the RAI manual
as a guide for completing assessments. They did not have an MDS policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676392
If continuation sheet
Page 5 of 9
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
676392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br
2468 Fm 1101
New Braunfels, TX 78130
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure the physician acted upon and documented his or her
rationale in the resident's medical record to the pharmacist report of any irregularities for 1 of 8 Residents
(Resident #42) whose records were reviewed for psychotropic use.
The facility failed to ensure the physician provided a rationale in response to the pharmacist
recommendation to evaluate the effectiveness and continued use of Remeron an appetite stimulant
(antidepressant) for Resident #42.
This deficient practice could affect any resident and could result in resident's receiving psychotropic
medications longer than required.
The findings were:
Review of Resident #42's annual MDS, dated [DATE], revealed she was admitted to the facility on [DATE]
with diagnoses including unspecified Dementia, Anxiety Disorder and unspecified protein calorie
malnutrition. Further review revealed she received an an antidepressant medication in the previous 7 days.
Review of Resident #42's Care Plan revised on 11/2/23 revealed she had potential for a nutritional problem
related dementia, malnutrition, dysphagia and history of weight loss. One of the interventions included that
she receive Remeron, an appetite stimulant as ordered.
Review of Resident #42's order summary, dated 1/26/24 revealed Resident #42 was ordered Mirtazapine
(Remeron) Tablet (anti-depressant) 7.5 MG Give 1 tablet by mouth at bedtime for appetite stimulant as of
4/29/22.
Review of Resident #42's MAR for January 2024 revealed she was receiving the medication, Remeron per
physician orders.
Review of a Pharmacist-Physician Communication, dated 11/9/23, revealed a recommendation to evaluate
the effectiveness and continued need for appetite stimulant, as the resident has received Remeron 7.5 MG
1 PO QHS sine 4/29/22. Further review revealed the physician's response was to continue Remeron with
no rationale noted.
Interview on 01/26/24 at 03:41 PM with the DON confirmed according to Resident #42's physician orders
she was receiving Remeron 7.5 MG 1 PO QHS sine 4/29/22. The DON stated she and the ADON were
responsible for ensuring the physician responsed to pharmacist recommendations to ensure residents
received medication as needed. She stated Resident #42's physician responded to the pharmacist's by
notating to continue the medication Remeron. The DON stated she believed this was sufficient.
Interview on 1/27/24 at 1:30 PM with the DON revealed she provided a copy of the facility policy,
Medication (Drug) Regimen Review (MRR) and stated according to this policy, the physician had to provide
a rationale if there was to be no change to the medication. The DON further stated that Resident #42's
physician did not provide a rationale to the pharmacist's recommendation.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676392
If continuation sheet
Page 6 of 9
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
676392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br
2468 Fm 1101
New Braunfels, TX 78130
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of facility policy, Medication (Drug) Regimen Review (MRR) revised 1.2022 read: It is the policy of
this facility that the drug regimen of each resident will be reviewed at least once a month by a licensed
pharmacist. A medication regimen review (MRR) includes a review of the resident's medical chart. Identified
irregularities will be documented on a separate written report that includes the resident's name, the relevant
drug, and the irregularity identified. The report will be sent to the attending physician, the facility's Medical
Director and the Director of Nursing Services (DNS) to be acted upon. 4. a. MRR recommendations to
physician: The attending physician will document within 30 days in the resident's medical record that the
identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is no
change inn the medication, the attending physician will document his or her rationale in the resident
medical record.
Event ID:
Facility ID:
676392
If continuation sheet
Page 7 of 9
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
676392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br
2468 Fm 1101
New Braunfels, TX 78130
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve
food in accordance with professional standards for food service safety in the facility's only kitchen.
Residents Affected - Few
The Dietary Manager and [NAME] A failed to wear beard restraints while working in the kitchen.
This failure could place residents who receive food prepared in the facility's only kitchen by placing them at
risk for food-borne illness and food contamination.
Findings include:
Observation of the facility's kitchen on 01/24/2024 at 11:10 AM revealed the Dietary manager cutting
tomatoes while having his beard restraint off his face and under his chin. Staff was observed as having
facial hair around his mouth and on his chin.
Interview with the Dietary Manager on 01/24/2024 at 11:20 AM revealed anyone entering the kitchen must
wear hair restraints and beard restraints if needed. Staff must wash hands before doing anything in the
kitchen. Staff wereare trained on this when hired and during their food handler course. The Dietary
manager stated wearing hair and beard restraints wasis important to prevent the food from becoming
contaminated. If hair and beard restraints wereare not worn hair could get into the food and served to the
residents causing them to get sick.
Observation on 01/24/2024 at 11:50 AM revealed [NAME] A entering the kitchen wearing a hair restraint
but not a beard restraint. [NAME] A walked past area where food was being plated and washed his hands.
[NAME] A was observed having facial hair around his mouth and on his chin. [NAME] A walked past the
area where food was being plated again to get a beard restraint that are kept outside the kitchen door.
Interview with [NAME] A on 01/24/2024 at 12:35 PM revealed when entering the kitchen staff wereare to
wear hair nets and bared nets then wash hands. [NAME] A stated hair nets ensure that hair does not get
into the food. If hair got into the food, it would be contaminated and cannot be served to residents.
Interview with the Admin on 01/25/2024 at 5:28 PM revealed kitchen staff wereare required to hold a
current Texas Food Handler Safety Certification. Kitchen staff wereare trained upon hiring based by using
the Texas Food Establishment Rules and FDA Food code. The Admin stated that per Texas Food
Establishment Rules, all staff are to wear hair restraints and beard restraints when applicable. The Dietary
Manager is responsible to ensure staff are trained and wearing hair restraints appropriately.
Record review of the Texas Food Establishment Rules 228.223. (f) on 01/26/2024 states Personal hygiene.
Employees shall conform to good hygienic practices as required in in Food Code, Subparts 2-301-304 and
2-401-402.
Record review of FDA Food code 2022 on 01/26/2024 states Except as provided in, (B) of this section,
FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676392
If continuation sheet
Page 8 of 9
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
676392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br
2468 Fm 1101
New Braunfels, TX 78130
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 0812
Level of Harm - Minimal harm
or potential for actual harm
and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting
exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and
SINGLE-USE ARTICLES.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676392
If continuation sheet
Page 9 of 9
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
FAQ · About this visit
Common questions about this visit
What happened during the January 27, 2024 survey of LEGEND OAKS HEALTHCARE AND REHABILITATION - NEW BR?
This was a inspection survey of LEGEND OAKS HEALTHCARE AND REHABILITATION - NEW BR on January 27, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LEGEND OAKS HEALTHCARE AND REHABILITATION - NEW BR on January 27, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.