Legend Oaks Healthcare And Rehabilitation Center G
LEGEND OAKS HEALTHCARE AND REHABILITATION CENTER G in Gladewater, TX — inspection on May 23, 2026.
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
During an interview on 5/23/2026 at 4:20 PM, the ADM said he expected the nurses to place orders from the Wound Care Specialist in the EMR.
The ADM said he did not know when the orders should be placed in the EMR.
The ADM said the treatment nurse dealt with the Wound Care Specialist.
The ADM said the treatment nurse, ADON, and DON was responsible for putting the orders in.
The ADM said he could not tell me what could happen if the treatment orders were not being followed.
The ADM said the charge nurse and treatment nurse were responsible for reporting a change in condition or new wound to the family.
The ADM said it would be documented in the EMR.
The ADM said he expected the nurse to document the family was notified even if the family was in the room.
Record review of facility policy titled, Skin and Wound Monitoring and Management, revised 4/2025, indicated, .It is the policy of this facility that:
- A resident having pressure injury (s) receives necessary treatment and services to promote
healing, prevent infection, and prevent new, avoidable pressure injuries from developing.
Purpose.1.
Promote interventions that prevent pressure injury development. 2.
Promote the healing of pressure injuries that are present .3.
Prevent the development of additional, avoidable pressure injury.Facility nursing staff will identify and document in the resident's clinical record.Deep tissue pressure injury: Intact or non-intact skin with persistent non-blanchable deep red, maroon or purple discoloration.Procedure: a.
Resident assessment: The nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take following actions.a.
Complete Initial admission Record, Braden scale.b.
Braden scale for pressure injury risk.c.
Identify risk factors.d.
Risk factors identified on assessment should be documented.e.
Develop an individualized person-centered care plan.f.
Skin and wound assessment.j.
Treatments per physician order should be documented in the resident's clinical record at the time they are administered. 6.
Monitoring.a.
Daily via medication administration and treatment administration record.Confirm all orders have been implemented as ordered.Weekly via skin weekly committee.Prepare and maintain skin committee review notes and recommendations in the resident's clinical record.document and implement recommended additions or changes to care plan in the resident clinical record.
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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.