Nursing home in Kyle, Texas
Legend Oaks Healthcare and Rehabilitation-Kyle
Medicare and Medicaid
1640 Fairway, Kyle, TX 78640
(512) 268-1003
CMS star ratings
CMS gives this nursing home an overall star rating of 3 out of 5. Each rating is compared with the mean of rated nursing homes in Texas (1,165 for the overall rating) and in the U.S. (14,565). How to read an inspection report.
Overall rating
- This nursing home3
- Texas average2.7 (1,165 rated)
- U.S. average3.0 (14,565 rated)
Health inspections
- This nursing home3
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
- This nursing home2
- Texas average1.9 (1,163 rated)
- U.S. average2.9 (14,494 rated)
Quality measures
- This nursing home3
- Texas average3.7 (1,162 rated)
- U.S. average3.6 (14,495 rated)
Health inspections
Most recent standard health inspection (rating cycle 1): Dec 12, 2025. CMS counts 8 health deficiencies in rating cycle 1.
- This nursing home8
- Texas average9.4 (1,171 with data)
- U.S. average9.2 (14,652 with data)
Rating cycle 1 health deficiencies. Averages include every nursing home with a count in the CMS file; fewer is better.
Deficiencies since Sep 30, 2023
Inspectors cited 18 health deficiencies on 6 inspection dates since Sep 30, 2023. By level of harm: 1 actual harm, 17 potential for harm.
- 0 Immediate jeopardy to resident health or safety
- 1 Actual harm
- 17 No actual harm, potential for more than minimal harm
- 0 No actual harm, potential for minimal harm
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| May 26, 2026 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Jun 30, 2026 |
| May 26, 2026 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Jun 30, 2026 |
| Jan 29, 2026 | F0584 | Honor 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.Resident Rights Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Feb 19, 2026 |
| Jan 29, 2026 | F0552 | Ensure that residents are fully informed and understand their health status, care and treatments.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Feb 19, 2026 |
| Dec 12, 2025 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies | G Actual harm, isolated | Standard | Deficient, Provider has date of correction Dec 18, 2025 |
| Dec 12, 2025 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | F Potential for harm, widespread | Standard | Deficient, Provider has date of correction Dec 15, 2025 |
| Dec 12, 2025 | F0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 18, 2025 |
| Dec 12, 2025 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 15, 2025 |
| Nov 20, 2024 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Nov 21, 2024 |
| Nov 20, 2024 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and Exploitation Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Nov 21, 2024 |
Show the other 8 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Sep 5, 2024 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Sep 6, 2024 |
| Sep 5, 2024 | F0583 | Keep residents' personal and medical records private and confidential.Resident Rights Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Sep 6, 2024 |
| Sep 5, 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Sep 6, 2024 |
| Sep 5, 2024 | F0578 | 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.Resident Rights Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Sep 6, 2024 |
| Sep 5, 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Sep 6, 2024 |
| Sep 5, 2024 | F0791 | Provide or obtain dental services for each resident.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Oct 7, 2024 |
| Sep 5, 2024 | F0919 | Make sure that a working call system is available in each resident's bathroom and bathing area.Environmental Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Sep 6, 2024 |
| Nov 21, 2023 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and Exploitation Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jan 26, 2024 |
Staffing
Total nurse staffing
Reported hours per resident per day.
- This nursing home3.38 hours
- Texas average3.39 hours (1,148 with data)
- U.S. average3.86 hours (14,351 with data)
Registered nurse staffing
Reported hours per resident per day.
- This nursing home0.36 hours
- Texas average0.43 hours (1,148 with data)
- U.S. average0.69 hours (14,351 with data)
Nursing staff turnover
Share of nursing staff who left during the year, as reported to CMS.
- This nursing home38.1%
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 1 penalty for this nursing home: 1 fine totaling $8,407, and 0 payment denials. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 126 |
|---|---|
| Average residents per day | 115.9 |
| Ownership | For profit - Limited Liability company |
| Provider type | Medicare and Medicaid |
| Inside a hospital | No |
| Continuing care retirement community | No |
| Resident and family council | Resident |
| Automatic sprinklers in all required areas | Yes |
| Chain | The Ensign Group (344 facilities) |
| Legal business name | GUADALUPE COUNTY HOSPITAL BOARD |
| First approved for Medicare and Medicaid | Feb 8, 2011 |
| County | Hays |
| CMS certification number | 676272 |
Also in Kyle
| Hospital | CMS overall rating | Type | Emergency services |
|---|---|---|---|
| Ascension Seton Hays | Acute Care Hospitals | Yes |