Legend Oaks Healthcare and Rehabilitation-KyleCMS ratings, inspections and fines
- Address
- 1640 Fairway, Kyle, TX 78640
- CCN
- 676272
- Ownership type
- For-profit, limited liability company
- Certified beds
- 126
- Chain
- The Ensign Group
- Residents per day
- 116
- CMS flags
- None in the CMS record
The watch list stays in this browser. After each CMS update, it shows the values that changed at the homes on the list.
CMS gives Legend Oaks Healthcare and Rehabilitation-Kyle an overall rating of 3 of 5 stars. The last standard survey was on 12 Dec 2025. The latest survey cycle has 8 health citations. The median for nursing homes in Texas is 8. CMS lists 1 fine of $8,407 for this home in its penalties file.
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is based on three individual domains, a change in any one of the domains can affect the overall rating. Any new data for a nursing home could potentially change a star rating domain.
Centers for Medicare & Medicaid Services, Five-Star Quality Rating System: Technical Users' Guide, July 2026. CMS processed this record on .
Since the last CMS update
The site has no recorded change for this home. In each CMS update, the site compares the ratings, the penalties and the citations of each home.
Ratings
CMS gives each home 1 to 5 stars for health inspections, for staffing and for quality measures, and one overall rating.
| Rating (1 to 5 stars) | This home | Hays County median | Texas median | US average (CMS) |
|---|---|---|---|---|
| Overall rating | 3 | 3.0 | 3.0 | 3.0 |
| Health inspection rating | 3 | 3.0 | 3.0 | 2.8 |
| Staffing rating | 2 | 2.0 | 2.0 | 2.9 |
| Quality measure rating | 3 | 4.0 | 4.0 | 3.6 |
A median is the middle value of the homes in the group: 6 homes in the county, 1,177 homes in the state. What the CMS star ratings measure
Citations by survey cycle
CMS keeps the last three cycles, and cycle 1 is the latest. A cycle has one standard survey. Citations from complaint and infection control inspections go into cycles of 12 months.
| Survey cycle | Standard survey | Citations | Texas median |
|---|---|---|---|
| Cycle 1 (latest) | 12 Dec 2025 | 8 | 8 |
| Cycle 2 | 5 Sep 2024 | 9 | 8 |
| Cycle 3 | No date | 12 | 8 |
Health citations
The record of one deficiency in an inspection. One inspection can give many citations.
Scope and severity. A letter from A to L on each citation. Scope is the number of residents that the deficiency affected. Severity is the level of harm.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | J0 | K0 | L0 |
| Actual harm that is not immediate jeopardy | H0 | I0 | |
| No actual harm, potential for more than minimal harm | |||
| No actual harm, potential for minimal harm | A0 | B0 | C0 |
Survey cycle 1 (latest): 8 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 26 May 2026 | F0695 | Provide safe and appropriate respiratory care for a resident when needed. | E | Complaint investigation | 30 Jun 2026 |
| 26 May 2026 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E | Complaint investigation | 30 Jun 2026 |
| 29 Jan 2026 | F0552 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | Complaint investigation | 19 Feb 2026 |
| 29 Jan 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. | E | Complaint investigation | 19 Feb 2026 |
| 12 Dec 2025 | F0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D | Standard survey | 18 Dec 2025 |
| 12 Dec 2025 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Standard survey | 18 Dec 2025 |
| 12 Dec 2025 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard survey | 15 Dec 2025 |
| 12 Dec 2025 | F0880 | Provide and implement an infection prevention and control program. | D | Standard survey | 15 Dec 2025 |
Survey cycle 2: 9 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 20 Nov 2024 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint investigation | 21 Nov 2024 |
| 20 Nov 2024 | F0880 | Provide and implement an infection prevention and control program. | E | Complaint investigation | 21 Nov 2024 |
| 5 Sep 2024 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E | Standard survey | 6 Sep 2024 |
| 5 Sep 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. | D | Standard survey | 6 Sep 2024 |
| 5 Sep 2024 | F0583 | Keep residents' personal and medical records private and confidential. | E | Standard survey | 6 Sep 2024 |
| 5 Sep 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard survey | 6 Sep 2024 |
| 5 Sep 2024 | F0791 | Provide or obtain dental services for each resident. | D | Standard survey | 7 Oct 2024 |
| 5 Sep 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard survey | 6 Sep 2024 |
| 5 Sep 2024 | F0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. | D | Standard survey | 6 Sep 2024 |
Survey cycle 3: 12 citations
The CMS provider file has no standard survey date for this cycle.
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 21 Nov 2023 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 26 Jan 2024 |
| 10 Aug 2023 | F0552 | Ensure that residents are fully informed and understand their health status, care and treatments. | E | Complaint investigation | 22 Aug 2023 |
| 10 Aug 2023 | F0658 | Ensure services provided by the nursing facility meet professional standards of quality. | E | Complaint investigation | 22 Aug 2023 |
| 10 Aug 2023 | F0758 | 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. | E | Complaint investigation | 22 Aug 2023 |
| 30 Jun 2023 | 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. | D | Standard survey | 28 Jul 2023 |
| 30 Jun 2023 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard survey | 28 Jul 2023 |
| 30 Jun 2023 | F0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Standard survey | 28 Jul 2023 |
| 30 Jun 2023 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Standard survey | 28 Jul 2023 |
| 30 Jun 2023 | F0758 | 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. | D | Standard survey | 28 Jul 2023 |
| 30 Jun 2023 | F0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D | Standard survey | 28 Jul 2023 |
| 30 Jun 2023 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard survey | 28 Jul 2023 |
| 30 Jun 2023 | F0814 | Dispose of garbage and refuse properly. | D | Standard survey | 28 Jul 2023 |
The requirement text is the CMS summary of the F-tag. It is not the report of the surveyor. How to read an inspection report
Penalties
A fine, or a payment denial: a period in which Medicare or Medicaid does not pay for new admissions. The CMS penalties file holds three years.
| Date | Type | Fine | Days without payment |
|---|---|---|---|
| 12 Dec 2025 | Fine | $8,407 |
Staffing
Hours per resident per day. The nurse hours for one resident on an average day. CMS calculates the figure from the hours that the home reports for a quarter.
| Staff | This home | Texas median | Texas average (CMS) |
|---|---|---|---|
| All nurse staff | 3.38 | 3.30 | 3.39 |
| Registered nurses (RN) | 0.36 | 0.40 | 0.43 |
| Licensed practical nurses (LPN) | 0.96 | 0.95 | |
| Nurse aides | 2.06 | 2.00 | |
| All nurse staff, weekends | 2.74 | 2.90 | 2.98 |
- Nurse staff turnover in a year
- 38.1%
- Nurse staff turnover, Texas median
- 52.1%
- RN turnover in a year
- 60.0%
- Administrators who left in a year
- 0
Homes report the hours to CMS in the Payroll-Based Journal.
Quality measures
A figure that CMS calculates from the assessments of residents. One example is the percentage of long-stay residents with a fall and a major injury.
| Measure (CMS text) | Residents | This home | Texas median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 21.7% | 14.9% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | 0.0% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.1% | 0.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.9% | 3.0% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.3% | 0.7% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 26.3% | 12.4% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.4% | 3.4% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 3.7% | 8.3% | 13.4% |
For each measure in this table, CMS gives more points in the quality measure rating for a lower percentage. The site calculates the medians from the CMS file. What the CMS star ratings measure
Ownership
An organisation in the CMS ownership file. CMS records its role, for example an ownership interest, operational or managerial control, or a mortgage interest.
- Ownership type
- For-profit, limited liability company
- Legal business name
- Guadalupe County Hospital Board
- Chain
- The Ensign Group (342 homes in the CMS chain file)
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Guadalupe County Hospital Board | 5% or greater direct ownership interest | 100% | 1 Apr 2017 |
| Treaty Healthcare, Inc | Operational/managerial control | 1 Apr 2017 | |
| Ensign Services Inc | Adp of the snf | 1 May 2016 | |
| National Health Investors, Inc. | Adp of the snf | 1 Apr 2017 | |
| Texas Nhi Investors, LLC | Adp of the snf | 1 Apr 2017 | |
| Treaty Healthcare, Inc | Adp of the snf | 7 Oct 2025 |
The site shows organisations only. It does not show the names of persons.
Other homes in Hays County
| Nursing home | City | Overall rating | Citations, latest cycle | Fines | Last standard survey | |
|---|---|---|---|---|---|---|
| San Marcos Rehabilitation and Healthcare Center | San Marcos | 1 of 5 | 3 | $33,891 | 1 Oct 2025 | |
| Hays Nursing and Rehabilitation Center | San Marcos | 3 of 5 | 6 | $8,226 | 5 Mar 2026 | |
| Deer Creek Nursing and Rehabilitation | Wimberley | 1 of 5 | 16 | $75,581 | 26 Jun 2025 | |
| Cypress Healthcare and Rehabilitation Center | San Marcos | 1 of 5 | 12 | $221,139 | 17 Apr 2025 | |
| Avir at Dripping Springs | Dripping Springs | 4 of 5 | 1 | $0 | 31 Dec 2025 |
Official channels
- Care Compare record of this nursing homeMedicare.gov. The official CMS record of this home.
- Texas Health and Human Services: complaint and incident intakeThe complaint page of the State Survey Agency for Texas, from the CMS list of agencies.
- Contact information for State Survey AgenciesCMS. The web address and the telephone number of the State Survey Agency of each state. These agencies investigate complaints about nursing homes.
- Filing a complaintMedicare.gov. The page names the State Survey Agency as the place for a complaint about nursing home care or facility conditions.
- Eldercare LocatorAdministration for Community Living. A public service that connects older adults and their families to local services. Telephone: 1-800-677-1116.
Cite this page
Centers for Medicare & Medicaid Services, Care Compare. Record of Legend Oaks Healthcare and Rehabilitation-Kyle (CCN 676272). Data processed 1 Aug 2026. Elder Care Record, https://eldercarerecord.com/facility/legend-oaks-healthcare-and-rehabilitation-kyle-kyle-tx-676272/
Provenance
- Licence
- US government work, public domain
- CMS processed the data on
A program makes this page from the CMS files, and the same files always give the same text. How the site makes the figures. Report an error.
Questions
- When was Legend Oaks Healthcare and Rehabilitation-Kyle last inspected?
- The latest inspection with a citation in the CMS record was on 26 May 2026. It was a complaint investigation. It gave 2 citations. The standard survey before the last one was on 5 Sep 2024.
- Who operates Legend Oaks Healthcare and Rehabilitation-Kyle?
- The CMS record gives the ownership type as for-profit, limited liability company. CMS lists the home in the chain The Ensign Group. The CMS ownership file names Treaty Healthcare, Inc for operational or managerial control. This site does not show the names of persons.
- Is Legend Oaks Healthcare and Rehabilitation-Kyle a Special Focus Facility?
- No. The CMS provider file lists no Special Focus status for this home. CMS lists 6 homes in Texas as Special Focus Facilities and 30 as candidates.
- Where does the data on this page come from?
- The data comes from the CMS Care Compare files for nursing homes. CMS processed the files on 1 Aug 2026. The Care Compare record on Medicare.gov is the official record of the home.