All citations for Legend Oaks Healthcare and Rehabilitation Center -

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Legend Oaks Healthcare and Rehabilitation Center -

Last standard health inspection on record

June 6, 2025

Showing 1 to 20 of 20 citations

  1. Immediate jeopardy to resident health or safety

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

    Pattern (more than a few residents). CMS level K.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of April 23, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 24, 2024).

  2. Immediate jeopardy to resident health or safety

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

    Pattern (more than a few residents). CMS level K.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of April 23, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 24, 2024).

  3. No harm, with potential for more than minimal harm

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

    Widespread (many residents). CMS level F.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of May 10, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 11, 2024).

  4. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of June 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 20, 2025).

  5. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of June 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 20, 2025).

  6. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of June 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 20, 2025).

  7. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of March 2, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 23, 2023).

  8. No harm, with potential for more than minimal harm

    Provide activities to meet all resident's needs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0679, Quality of Life and Care Deficiencies. Inspection of March 2, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 23, 2023).

  9. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of March 2, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 23, 2023).

  10. No harm, with potential for more than minimal harm

    Ensure each resident receives an accurate assessment.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0641, Resident Assessment and Care Planning Deficiencies. Inspection of December 1, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (December 12, 2025).

  11. No harm, with potential for more than minimal harm

    Provide for the safe, appropriate administration of IV fluids for a resident when needed.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0694, Quality of Life and Care Deficiencies. Inspection of December 1, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (December 12, 2025).

  12. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0726, Nursing and Physician Services Deficiencies. Inspection of December 1, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (December 12, 2025).

  13. No harm, with potential for more than minimal harm

    Ensure that residents are free from significant medication errors.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0760, Pharmacy Service Deficiencies. Inspection of December 1, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (December 12, 2025).

  14. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of December 1, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (December 12, 2025).

  15. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0695, Quality of Life and Care Deficiencies. Inspection of June 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 20, 2025).

  16. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of June 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 20, 2025).

  17. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0880, Infection Control Deficiencies. Inspection of June 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 20, 2025).

  18. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of February 28, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 3, 2025).

  19. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of February 28, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 3, 2025).

  20. No harm, with potential for minimal harm

    Post nurse staffing information every day.

    Widespread (many residents). CMS level C.

    Health citation F-0732, Nursing and Physician Services Deficiencies. Inspection of December 1, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (December 12, 2025).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.