Legend Oaks Healthcare and Rehabilitation-Kyle
1640 Fairway, Kyle, TX 78640 · CCN 676272
Ratings
- Overall
- ★★★★☆ 4
- Health inspection
- ★★★☆☆ 3
- Quality measures
- ★★★★★ 5
- Staffing
- ★★☆☆☆ 2
Facility
- Ownership type
- For profit - Corporation
- Certified beds
- 126
- Avg residents/day
- 112.4
- Phone
- 5122681003
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2024-09-05 | 9 | 9.1 | 9.5 | -0.1 better |
| 2 | 2023-06-30 | 10 | 9.4 | 9.8 | +0.6 worse |
| 3 | 2022-04-28 | 7 | 8.1 | 9.3 | -1.1 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 2 |
| Resident rights | 5 |
| Nutrition and dietary | 1 |
| Environmental | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.25 | 32.6% |
| RN staffing (reported) | 0.30 | 54.5% |
| Total nurse staffing (adjusted) | 3.44 | — |
Fines & penalties
- Total fines
- $12,735
- Number of fines
- 1
- Number of penalties
- 1
- Payment denials
- 0
Chain
- Chain
- THE ENSIGN GROUP
- Facilities in chain
- 329
- Chain avg overall
- 3.20 / 5
Inspection citations (26)
- DF0552Ensure that residents are fully informed and understand their health status, care and treatments.2026-01-29 · Health · corrected 2026-02-19
Potential for more than minimal harm
- EF0584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.2026-01-29 · Health · corrected 2026-02-19
Potential for more than minimal harm
- DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2024-11-20 · Health · corrected 2024-11-21
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2024-11-20 · Health · corrected 2024-11-21
Potential for more than minimal harm
- EF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-09-05 · Health · corrected 2024-09-06
Potential for more than minimal harm
- DF0578Honor 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.2024-09-05 · Health · corrected 2024-09-06
Potential for more than minimal harm
- EF0583Keep residents' personal and medical records private and confidential.2024-09-05 · Health · corrected 2024-09-06
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-09-05 · Health · corrected 2024-09-06
Potential for more than minimal harm
- DF0791Provide or obtain dental services for each resident.2024-09-05 · Health · corrected 2024-10-07
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-09-05 · Health · corrected 2024-09-06
Potential for more than minimal harm
- DF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2024-09-05 · Health · corrected 2024-09-06
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-11-21 · Health · corrected 2024-01-26
Potential for more than minimal harm
- EF0552Ensure that residents are fully informed and understand their health status, care and treatments.2023-08-10 · Health · corrected 2023-08-22
Potential for more than minimal harm
- EF0658Ensure services provided by the nursing facility meet professional standards of quality.2023-08-10 · Health · corrected 2023-08-22
Potential for more than minimal harm
- EF0758Implement 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.2023-08-10 · Health · corrected 2023-08-22
Potential for more than minimal harm
- DF0578Honor 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.2023-06-30 · Health · corrected 2023-07-28
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-06-30 · Health · corrected 2023-07-28
Potential for more than minimal harm
- DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2023-06-30 · Health · corrected 2023-07-28
Potential for more than minimal harm
- EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-06-30 · Health · corrected 2023-07-28
Potential for more than minimal harm
- DF0758Implement 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.2023-06-30 · Health · corrected 2023-07-28
Potential for more than minimal harm
- DF0805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.2023-06-30 · Health · corrected 2023-07-28
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-06-30 · Health · corrected 2023-07-28
Potential for more than minimal harm
- DF0814Dispose of garbage and refuse properly.2023-06-30 · Health · corrected 2023-07-28
Potential for more than minimal harm
- EF0800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.2023-06-13 · Health · corrected 2023-06-22
Potential for more than minimal harm
- EF0803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.2023-06-13 · Health · corrected 2023-06-22
Potential for more than minimal harm
- EF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2023-06-13 · Health · corrected 2023-06-22
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| GUADALUPE COUNTY HOSPITAL BOARD | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2017-04-01 |
| TREATY HEALTHCARE, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-04-01 |
| FOWERS, MATTHEW | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2019-03-12 |
| KROL, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2016-05-01 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | — | 2017-04-01 |
| GANN, KODY | Individual | CORPORATE OFFICER | — | 2021-02-01 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | — | 2011-03-01 |
Other facilities in Kyle
| Name | Overall | Beds |
|---|
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.