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Complaint Investigation

Legend Oaks Healthcare And Rehabilitation - New Br

Inspection Date: September 10, 2025
Total Violations 2
Facility ID 676392
Location NEW BRAUNFELS, TX
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Inspection Findings

F-Tag F0804

Nutrition and Dietary Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident #4's admission Record dated 9/10/2025 was documented he was admitted on 7/12024 with diagnoses of Muscular Dystrophy (a group of genetic disorders that cause progressive muscle weakness and loss. contracture to multiple sites, muscle weakness (difficulty swallowing, involves trouble moving food or liquid from the mouth to the stomach), cognitive communications deficit, and need for assistance with personal care. Record review of Resident #4's consolidated orders for September 2025 was documented

he had a regular diet. Record review of Resident #4's Quarterly MDS dated [DATE REDACTED] was documented BIMS score 15/15 (cognitively intact), and ADL for eating was independent. Record review of Resident #4's Care Plan dated 8/18/2025 was documented for eating he required a tray set up assistance and supervision for meals. Observation on 9/9/2025 at 12:18 PM in the Dining room revealed Resident # 4 was sitting down and [NAME] his lunch and had the alternate hamburger, the bread was not burned. Interview on 9/9/2025 at 12:19 PM in the Dining room Resident #4 stated the residents often have burned food and does not eat it or ask for an alternative. Interview on 9/10/2025 at 2:39 PM DON had no response when discussed the bread was burned at bottom for lunch. Interview on 9/10/2025 at 2:44 PM FSM stated she did help the cook with

the lunch meal but did not see any burned bread or get complaints. Policy requested from Administrator on 09/10/2025, Administrator provided surveyor with Texas Food Establishment Rules, dated August 2021

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

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)

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F-Tag F0887

Infection Control Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited LEGEND OAKS HEALTHCARE AND REHABILITATION - NEW BR in NEW BRAUNFELS, TX for a deficiency under regulatory tag F-F0887 during a complaint investigation conducted on 2025-09-10.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 2 deficiencies cited during this inspection of LEGEND OAKS HEALTHCARE AND REHABILITATION - NEW BR.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-15.

📋 Inspection Summary

LEGEND OAKS HEALTHCARE AND REHABILITATION - NEW BR in NEW BRAUNFELS, TX inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NEW BRAUNFELS, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LEGEND OAKS HEALTHCARE AND REHABILITATION - NEW BR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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