Legend Oaks Healthcare And Rehabilitation - New Br
LEGEND OAKS HEALTHCARE AND REHABILITATION - NEW BR in NEW BRAUNFELS, TX — inspection on April 29, 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
Based on observations, interviews, and record review the facility failed to ensure all drugs and
authorized personnel to have access to the keys, for 1 of 6 medication carts (the 400-hall medication cart) reviewed for security. LVN B left the 400-hall medication cart unsupervised, unattended, and unlocked for more than 9 minutes on 4/28/2026.
This failure could place residents at risk for misappropriation of property and or not receiving the therapeutic effects of their medications.The findings include: During an observation and interview on 4/28/2026 at 9:10 AM, revealed the 400-hall with a medication cart positioned at the beginning of the hall.
The medication cart was unattended, unsupervised, and unlocked.
Continued observation revealed 2 staff walked by the unlocked medication cart, without recognizing the cart was unlocked.
Residents were observed ambulating the facility, including the 400-hall.
The State Surveyor intervened and alerted LVN A. LVN A stated the medication cart was the 400-hall medication cart and was assigned to LVN B. LVN A stated the cart housed residents' injectable insulin and oral medications.
During an interview on 4/28/2026 at 10:15 AM, the DON stated her expectation and nurse training was for nurses to lock their medication carts when the cart was not in use.
The DON stated the potential negative outcome could be uncontrolled medications. A record review of the facility's undated Medication Administration and General Guidelines policy revealed, Medications are administered as prescribed, in accordance with state regulations using good nursing principles and practices and only by persons legally authorized to do so. procedure: . when administering as needed medications at times other than medication pass, the dose may be prepared in the medication cart storage area and taken to the residence bedside, leaving the cart locked and secured.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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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.