All citations for Legend Oaks Healthcare and Rehabilitation - West S
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.
Last standard health inspection on record
January 29, 2026
Showing 1 to 23 of 23 citations
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.
The home gave a date the problem would be corrected (April 15, 2024).
No harm, with potential for more than minimal harm
Ensure residents have reasonable access to and privacy in their use of communication methods.
The home gave a date the problem would be corrected (November 22, 2024).
No harm, with potential for more than minimal harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
The home gave a date the problem would be corrected (July 3, 2026).
No harm, with potential for more than minimal harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
The home gave a date the problem would be corrected (July 3, 2026).
No harm, with potential for more than minimal harm
Ensure each resident receives an accurate assessment.
The home gave a date the problem would be corrected (February 18, 2026).
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.
The home gave a date the problem would be corrected (February 18, 2026).
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.
The home gave a date the problem would be corrected (February 18, 2026).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (February 18, 2026).
No harm, with potential for more than minimal harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
The home gave a date the problem would be corrected (February 18, 2026).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
The home gave a date the problem would be corrected (November 22, 2024).
No harm, with potential for more than minimal harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
The home gave a date the problem would be corrected (May 14, 2026).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (May 14, 2026).
No harm, with potential for more than minimal harm
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
The home gave a date the problem would be corrected (February 18, 2026).
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.
The home gave a date the problem would be corrected (February 18, 2026).
No harm, with potential for more than minimal harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
The home gave a date the problem would be corrected (February 18, 2026).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (December 10, 2025).
No harm, with potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
The home gave a date the problem would be corrected (November 22, 2024).
No harm, with potential for more than minimal harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
The home gave a date the problem would be corrected (April 15, 2024).
No harm, with potential for more than minimal harm
Assure that each resident’s assessment is updated at least once every 3 months.
The home gave a date the problem would be corrected (October 12, 2023).
No harm, with potential for more than minimal harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
The home gave a date the problem would be corrected (October 12, 2023).
No harm, with potential for more than minimal harm
PASARR screening for Mental disorders or Intellectual Disabilities
The home gave a date the problem would be corrected (October 12, 2023).
No harm, with potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
The home gave a date the problem would be corrected (October 12, 2023).
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.
The home gave a date the problem would be corrected (October 12, 2023).
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.