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Legend Oaks Healthcare And Rehabilitation - New Br

📍 2468 Fm 1101, New-braunfels, TX 78130 📞 (830) 420-6500 🛏️ 126 beds

Inspection History Overview

Detailed Inspection Reports

Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.

March 28, 2025 Complaint Investigation

March 28, 2025 Health Inspection

Fines and Penalties by Year

2022 2 penalties totaling $24,750

$15,000
Nov 18, 2022

Fine

$9,750
Nov 18, 2022

Fine

2019 1 penalties totaling $12,942

$12,942
Nov 9, 2019

Fine

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Health Violations by Year

2025 19 violations

Tag 0641 D Mar 28, 2025

Ensure each resident receives an accurate assessment.

✓ Corrected: Mar 31, 2025
Tag 0656 D Mar 28, 2025

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Mar 31, 2025
Tag 0692 D Mar 28, 2025

Provide enough food/fluids to maintain a resident's health.

✓ Corrected: Apr 3, 2025
Tag 0695 E Mar 28, 2025

Provide safe and appropriate respiratory care for a resident when needed.

✓ Corrected: Apr 2, 2025
Tag 0700 D Mar 28, 2025

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

✓ Corrected: Mar 31, 2025
Tag 0755 E Mar 28, 2025

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

✓ Corrected: Apr 2, 2025
Tag 0761 D Mar 28, 2025

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

✓ Corrected: Mar 31, 2025
Tag 0812 E Mar 28, 2025

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Mar 29, 2025
Tag 0940 D Mar 28, 2025

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

✓ Corrected: Apr 3, 2025
Tag 0941 D Mar 28, 2025

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

✓ Corrected: Apr 3, 2025
Tag 0943 D Mar 28, 2025

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

✓ Corrected: Apr 3, 2025
Tag 0944 D Mar 28, 2025

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

✓ Corrected: Apr 3, 2025
Tag 0945 D Mar 28, 2025

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

✓ Corrected: Apr 3, 2025
Tag 0946 D Mar 28, 2025

Provide training in compliance and ethics.

✓ Corrected: Apr 3, 2025
Tag 0949 D Mar 28, 2025

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

✓ Corrected: Apr 3, 2025
Tag 0602 D Feb 6, 2025

Protect each resident from the wrongful use of the resident's belongings or money.

✓ Corrected: Feb 7, 2025
Tag 0657 D Feb 6, 2025

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

✓ Corrected: Feb 7, 2025
Tag 0695 D Feb 6, 2025

Provide safe and appropriate respiratory care for a resident when needed.

✓ Corrected: Feb 12, 2025
Tag 0842 D Feb 6, 2025

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

✓ Corrected: Feb 7, 2025

2024 9 violations

Tag 0684 D Aug 3, 2024

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

✓ Corrected: Aug 4, 2024
Tag 0842 D Aug 3, 2024

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

✓ Corrected: Aug 4, 2024
Tag 0677 D Feb 29, 2024

Provide care and assistance to perform activities of daily living for any resident who is unable.

✓ Corrected: Feb 29, 2024
Tag 0609 D Jan 27, 2024

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

✓ Corrected: Feb 16, 2024
Tag 0623 D Jan 27, 2024

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

✓ Corrected: Feb 16, 2024
Tag 0636 D Jan 27, 2024

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

✓ Corrected: Feb 29, 2024
Tag 0756 D Jan 27, 2024

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

✓ Corrected: Feb 29, 2024
Tag 0812 D Jan 27, 2024

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Jan 29, 2024
Tag 0695 D Jan 20, 2024

Provide safe and appropriate respiratory care for a resident when needed.

✓ Corrected: Feb 11, 2024
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2022 7 violations

Tag 0578 D Nov 18, 2022

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

✓ Corrected: Dec 12, 2022
Tag 0685 D Nov 18, 2022

Assist a resident in gaining access to vision and hearing services.

✓ Corrected: Dec 31, 2022
Tag 0690 D Nov 18, 2022

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

✓ Corrected: Dec 15, 2022
Tag 0880 E Nov 18, 2022

Provide and implement an infection prevention and control program.

✓ Corrected: Nov 19, 2022
Tag 0944 E Nov 18, 2022

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

✓ Corrected: Dec 31, 2022
Tag 0609 D Jun 1, 2022

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

✓ Corrected: Sep 1, 2022
Tag 0610 D Jun 1, 2022

Respond appropriately to all alleged violations.

✓ Corrected: Sep 1, 2022

2021 10 violations

Tag 0641 D Sep 24, 2021

Ensure each resident receives an accurate assessment.

✓ Corrected: Oct 16, 2021
Tag 0686 D Sep 24, 2021

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

✓ Corrected: Oct 16, 2021
Tag 0697 D Sep 24, 2021

Provide safe, appropriate pain management for a resident who requires such services.

✓ Corrected: Oct 16, 2021
Tag 0755 D Sep 24, 2021

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

✓ Corrected: Oct 16, 2021
Tag 0802 F Sep 24, 2021

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

✓ Corrected: Oct 16, 2021
Tag 0804 E Sep 24, 2021

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

✓ Corrected: Oct 16, 2021
Tag 0812 F Sep 24, 2021

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Oct 16, 2021
Tag 0842 D Sep 24, 2021

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

✓ Corrected: Oct 16, 2021
Tag 0636 D Aug 10, 2021

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Tag 0842 D Aug 10, 2021

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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2020 4 violations

Tag 0607 D Oct 13, 2020

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

✓ Corrected: Oct 14, 2020
Tag 0609 D Oct 13, 2020

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

✓ Corrected: Oct 14, 2020
Tag 0610 D Oct 13, 2020

Respond appropriately to all alleged violations.

✓ Corrected: Oct 14, 2020
Tag 0880 E Mar 11, 2020

Provide and implement an infection prevention and control program.

✓ Corrected: Mar 12, 2020

2019 15 violations

Tag 0600 J Nov 9, 2019

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

✓ Corrected: Nov 10, 2019
Tag 0607 J Nov 9, 2019

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

✓ Corrected: Nov 10, 2019
Tag 0638 D Nov 9, 2019

Assure that each resident’s assessment is updated at least once every 3 months.

✓ Corrected: Nov 14, 2019
Tag 0656 E Nov 9, 2019

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Nov 14, 2019
Tag 0689 J Nov 9, 2019

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Nov 14, 2019
Tag 0690 D Nov 9, 2019

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

✓ Corrected: Nov 14, 2019
Tag 0695 E Nov 9, 2019

Provide safe and appropriate respiratory care for a resident when needed.

✓ Corrected: Nov 14, 2019
Tag 0697 D Nov 9, 2019

Provide safe, appropriate pain management for a resident who requires such services.

✓ Corrected: Nov 14, 2019
Tag 0700 E Nov 9, 2019

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

✓ Corrected: Nov 14, 2019
Tag 0726 E Nov 9, 2019

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

✓ Corrected: Nov 25, 2019
Tag 0759 D Nov 9, 2019

Ensure medication error rates are not 5 percent or greater.

✓ Corrected: Nov 25, 2019
Tag 0806 D Nov 9, 2019

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

✓ Corrected: Nov 19, 2019
Tag 0812 F Nov 9, 2019

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Nov 19, 2019
Tag 0842 D Nov 9, 2019

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

✓ Corrected: Nov 14, 2019
Tag 0880 E Nov 9, 2019

Provide and implement an infection prevention and control program.

✓ Corrected: Nov 25, 2019
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2018 11 violations

Tag 0580 D Nov 9, 2018

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

✓ Corrected: Nov 30, 2018
Tag 0659 E Nov 9, 2018

Provide care by qualified persons according to each resident's written plan of care.

✓ Corrected: Nov 30, 2018
Tag 0679 D Nov 9, 2018

Provide activities to meet all resident's needs.

✓ Corrected: Nov 30, 2018
Tag 0690 D Nov 9, 2018

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

✓ Corrected: Nov 30, 2018
Tag 0692 D Nov 9, 2018

Provide enough food/fluids to maintain a resident's health.

✓ Corrected: Nov 30, 2018
Tag 0695 D Nov 9, 2018

Provide safe and appropriate respiratory care for a resident when needed.

✓ Corrected: Nov 30, 2018
Tag 0700 E Nov 9, 2018

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

✓ Corrected: Nov 30, 2018
Tag 0755 D Nov 9, 2018

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

✓ Corrected: Nov 30, 2018
Tag 0756 D Nov 9, 2018

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

✓ Corrected: Nov 30, 2018
Tag 0805 E Nov 9, 2018

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

✓ Corrected: Nov 30, 2018
Tag 0812 D Nov 9, 2018

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Nov 30, 2018

2017 16 violations

Tag 0164 D Nov 10, 2017

Keep residents' personal and medical records private and confidential.

✓ Corrected: Nov 13, 2017
Tag 0241 D Nov 10, 2017

Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.

✓ Corrected: Nov 13, 2017
Tag 0278 E Nov 10, 2017

Ensure each resident receives an accurate assessment by a qualified health professional.

✓ Corrected: Nov 17, 2017
Tag 0279 E Nov 10, 2017

Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Nov 13, 2017
Tag 0282 D Nov 10, 2017

Provide care by qualified persons according to each resident's written plan of care.

✓ Corrected: Nov 13, 2017
Tag 0285 E Nov 10, 2017

Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients.

✓ Corrected: Nov 13, 2017
Tag 0309 E Nov 10, 2017

Provide necessary care and services to maintain or improve the highest well being of each resident .

✓ Corrected: Nov 13, 2017
Tag 0371 F Nov 10, 2017

Store, cook, and serve food in a safe and clean way.

✓ Corrected: Nov 13, 2017
Tag 0431 F Nov 10, 2017

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

✓ Corrected: Nov 13, 2017
Tag 0465 E Nov 10, 2017

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

✓ Corrected: Nov 13, 2017
Tag 0469 E Nov 10, 2017

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

✓ Corrected: Nov 13, 2017
Tag 0497 F Nov 10, 2017

1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews.

✓ Corrected: Nov 13, 2017
Tag 0514 E Nov 10, 2017

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

✓ Corrected: Nov 13, 2017
Tag 0518 F Nov 10, 2017

Train all employees on what to do in an emergency, and carry out unannounced staff drills.

✓ Corrected: Nov 13, 2017
Tag 0278 E May 10, 2017

Ensure each resident receives an accurate assessment by a qualified health professional.

✓ Corrected: May 29, 2017
Tag 0328 E May 10, 2017

Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.

✓ Corrected: May 29, 2017
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