Legend Oaks Healthcare And Rehabilitation - Fort W
Legend Oaks Healthcare and Rehabilitation - Fort W in Keller, TX — inspection on March 26, 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
was too unsteady to be out of bed, and it was safer for him to be in bed or in a wheelchair.
The Family
preferring to keep using his walker.
The family member stated the facility did not put any offloading or
another facility and doing better with therapy. In an interview on 03/26/26 at 11:00 AM, the Wound Care Nurse stated Resident #1 was admitted with the injury to his left elbow but the wound to his left heel was acquired in the facility.
She stated the most likely cause was his lack of mobility and friction from the bed and sheets.
She stated she was alerted to the wound on 02/11/26, and after assessing it she contacted the Wound Care Physician for treatment orders.
She stated when the resident was admitted they did not start off-loading practices because he was reported to be ambulatory and able to move about.
After the wound on the resident's heel developed, she placed the foam boot for padding and protection of the heel.
She stated the wound measured 5.5 cm X 5 cm on her first assessment. In an interview on 03/26/26 at 12:30 PM, the Director of Rehabilitation stated Resident #1 had made minimal progress in his mobility after working with Physical Therapy.
The resident remained unsteady and continued using his walker when out of bed. In an interview on 03/26/26 at 1:27 PM, LVN-C stated Resident #1 was confused at times, he would get out of bed without assistance to go to the bathroom.
The resident was unsteady when using his walker, and he was encouraged to remain in bed so he would not fall.
The resident did not want to participate in activities, and he spent most of his time in bed except when he was working with therapy. LVN-C stated she could not recall when the preventative measures were put in place but did know it was not until after he had the wound on his heel.
She stated since he was able to turn himself, and he was getting out of bed, they would not have necessarily implemented any precautionary measures.
She did not know what his Braden score was without being able to review his chart, but she did not think he was very high risk.In an interview on 03/26/26 at 2:00 PM, the Physician stated Resident #1 had a history of vascular issues and other medical problems that would have made him prone to pressure ulcers, but she could not say what caused the wound to develop. In an interview on 03/26/26 at 3:30 PM following the exit conference, the Administrator and the DON returned with the Physician on the phone.
The Physician stated Resident #1's pressure ulcer was unavoidable due to his vascular issues and his medical condition.
The DON stated with the resident being ambulatory, staff would not have placed heel protection boots on him.
The DON was unable to state if the resident's Braden Scale, scoring him as a moderate risk for pressure ulcers was accurate without reviewing it .