Legend Oaks Healthcare and Rehabilitation-Kyle

1640 Fairway
Kyle, TX, 78640
5122681003
CCN: 676272
4
Overall
3
Health
2
Staffing
5
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
KROL, MICHAELOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
TREATY HEALTHCARE, INCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
FOWERS, MATTHEWOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (1)
DateTypeAmount
2025-12-12Fine$13K
Health Deficiencies (26)
2026-01-29 · Health
E
F584 · Resident Rights Deficiencies
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.
D
F552 · Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
2024-11-20 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F600 · 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.
2024-09-05 · Health
D
F919 · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
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
F791 · Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
E
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
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.
E
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2023-11-21 · Health
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.
2023-08-10 · Health
E
F758 · 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.
E
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
E
F552 · Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
2023-06-30 · Health
D
F814 · Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
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
F805 · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
D
F758 · 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.
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
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
2023-06-13 · Health
E
F806 · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
E
F803 · Nutrition and Dietary Deficiencies
Ensure 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.
E
F800 · Nutrition and Dietary Deficiencies
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.25
3.68
RN Hrs/Resident/Day
0.30
0.54
LPN Hrs/Resident/Day
0.96
0.81
CNA Hrs/Resident/Day
1.98
2.33
PT Hrs/Resident/Day
0.21
0.12
Data as of 2026-03-01