LEGEND OAKS HEALTHCARE AND REHABILITATION CENTER G
1201 FM 2685, Gladewater, TX, 75647 · 9038452175
Legal business name: FANNIN COUNTY HOSPITAL AUTHORITY
On the CMS record
- Overall rating (CMS)
- 2 / 5
- Health inspection rating
- 2 / 5
- Staffing rating
- 2 / 5
- Certified beds
- 100
- Ownership type
- Government - Hospital district
- Chain
- THE ENSIGN GROUP
Inspection findings on record (39)
Quoted exactly as CMS published them. We do not rewrite findings.
— Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Recorded as corrected on .
— Resident Rights Deficiencies
Give residents a notice of rights, rules, services and charges.
Recorded as corrected on .
— Resident Rights Deficiencies
Ensure residents have reasonable access to and privacy in their use of communication methods.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Recorded as corrected on .
— Pharmacy Service Deficiencies
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.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Resident Rights Deficiencies
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Recorded as corrected on .
— Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Recorded as corrected on .
— Pharmacy Service Deficiencies
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.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Recorded as corrected on .
— Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Recorded as corrected on .
— Pharmacy Service Deficiencies
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.
Recorded as corrected on .
— Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Recorded as corrected on .
Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 676048