LEGEND OAKS HEALTHCARE AND REHABILITATION - NEW BR

2468 FM 1101
NEW BRAUNFELS, TX, 78130
8304206500
CCN: 676392
3
Overall
3
Health
2
Staffing
3
Quality
ChainTHE ENSIGN GROUP
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
GUADALUPE COUNTY HOSPITAL BOARD5% OR GREATER DIRECT OWNERSHIP INTEREST100%
BURNAM, SOONCORPORATE OFFICERNOT APPLICABLE
GANN, KODYCORPORATE OFFICERNOT APPLICABLE
KEETCH, CHADCORPORATE OFFICERNOT APPLICABLE
NEWSOME, GARRETTOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
RIVERWALK HEALTHCARE INCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
YU, HAORANOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Health Deficiencies (35)
2025-09-10 · Health
D
F887 · Infection Control Deficiencies
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.
E
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
2025-03-28 · Health
D
F949 · Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
D
F946 · Administration Deficiencies
Provide training in compliance and ethics.
D
F945 · Infection Control Deficiencies
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
D
F944 · Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
D
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
D
F941 · Administration Deficiencies
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
D
F940 · Administration Deficiencies
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F761 · 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.
E
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F700 · Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
E
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
2025-02-06 · Health
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F657 · 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.
D
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
2024-08-03 · Health
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2024-02-29 · Health
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
2024-01-27 · Health
D
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
D
F636 · Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
D
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2024-01-20 · Health
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
2022-11-18 · Health
E
F944 · Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F690 · 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.
D
F685 · Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
D
F578 · Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.52
3.68
RN Hrs/Resident/Day
0.37
0.54
LPN Hrs/Resident/Day
0.93
0.81
CNA Hrs/Resident/Day
2.22
2.33
PT Hrs/Resident/Day
0.23
0.12
Data as of 2026-03-01