Legend Oaks Healthcare And Rehabilitation Garland
Legend Oaks Healthcare and Rehabilitation Garland in Garland, TX — inspection on December 30, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
medications and for the staff to scan the room for any medications.
Record review of Resident #1's
self-administration of medications, no clear instructions for self-administrations, and no assessment
12/30/2025 at 8:29 AM revealed Resident #1 was in her wheelchair, awake. It was observed that there was a tube of topical analgesic cream on top of her overbed table that was beside her wheelchair.
The tube of analgesic cream was in plain view.
The resident nodded her head when asked if the analgesic cream was hers.
The resident nodded her head when asked if the analgesic cream had always been on her table. In an interview on 12/30/2025 at 11:06 AM, LVN C stated she was not aware there was a tube of topical analgesic cream inside Resident #1.
She said she did not notice it when she did her morning round.
She said the resident had dementia and might use it inappropriately like applying it to her eyes or mouth.
She said the resident did not even have an order for the analgesic cream.
She said the analgesic cream should be inside the nurse's carts and the nurses should be the one applying it if the resident needed it.
She said she would go to the resident's room and talk to the resident regarding removing the analgesic cream.
She said she would re-educate the family member about letting the nurses about any medication being brought to the facility.
She said since there was already an issue about a family member bringing medications, the more staff should be mindful of checking for any medications. In an interview on 12/30/2025 at 11:27 PM, the Administrator stated the expectation was for all the carts, nurses' carts, medication aide carts, and the wound care carts, crash carts would always be locked to protect the residents from getting any supplies and medications that they might be allergic to or used inappropriately. he said another expectation was for no medications were inside the residents' room to prevent accidental consumption that could result to adverse reactions like allergy, stomach upset, and irritations. He said he would coordinate with the ADONs to educate the staff about the matter. In an interview on 12/30/2025 at 12:44 PM, ADON A stated the carts should be locked every time they were left unattended.
She said the staff should lock the carts before leaving them to prevent unauthorized individuals from opening them.
She said confused residents might open the cart and ingest something to which they were allergic or use something inappropriately that could result to harm.
She said there was no emergency the night prior, so she did not know why and how long the crash cart was not locked.
She said another issue was if somebody got hold of the supplies and medications, staff might not have something to use in case of emergencies.
She said she would try to find out who left it open so she could remind the staff to always lock the crash cart.
She said all the nurses were responsible in making sure the crash cart was locked.
She said there should be no medication inside the rooms of the residents because of the danger of inappropriate use or overdose, especially if they had confusion or fading eyesight.
She said the topical analgesic cream was a medication for pain.
She said if the staff knew that family members were bringing medications, the more they should scan the room for any medications.
She said the expectation was for the staff to be observant to see if there were medications inside the residents' rooms and always lock the carts when not in use.
She said she initiate an in-service about the importance of the locking the carts and about scanning the residents' room for any medications.
Record review of the facility's policy titled Medication Access and Storage Policy/ Procedure - Nursing Clinical revised May 2007 reflected POLICY: It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls.
The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . PROCEDURES . 2.
Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications.
Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.