Legend Oaks Healthcare and Rehabilitation-Kyle

Name: Legend Oaks Healthcare and Rehabilitation-Kyle
Address: 1640 Fairway, Kyle, TX, 78640, US
Telephone: 5122681003

1640 Fairway, Kyle, TX 78640 · Hays County · 126 certified beds · avg 116 residents/day · certified since Feb 8, 2011

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

3/5

Health inspection rating (on-site)

Serious findings on record

$8,407

Fines, last 3 years

3.36

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Dec 12, 2025 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Dec 18, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (29)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
May 26, 2026	E · Potential for harm, repeated	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint
May 26, 2026	E · Potential for harm, repeated	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jan 29, 2026	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Jan 29, 2026	D · Potential for harm, one-off	The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint
Dec 12, 2025	▲ G · Actual harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Dec 12, 2025	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Dec 12, 2025	D · Potential for harm, one-off	The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that.
Dec 12, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Nov 20, 2024	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Nov 20, 2024	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Sep 5, 2024	E · Potential for harm, repeated	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Sep 5, 2024	E · Potential for harm, repeated	The facility did not keep residents' personal and medical information private and confidential.
Sep 5, 2024	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Sep 5, 2024	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Sep 5, 2024	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Sep 5, 2024	D · Potential for harm, one-off	The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.
Sep 5, 2024	D · Potential for harm, one-off	The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Nov 21, 2023	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Aug 10, 2023	E · Potential for harm, repeated	The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint
Aug 10, 2023	E · Potential for harm, repeated	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Aug 10, 2023	E · Potential for harm, repeated	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint
Jun 30, 2023	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jun 30, 2023	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jun 30, 2023	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Jun 30, 2023	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jun 30, 2023	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Jun 30, 2023	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Jun 30, 2023	D · Potential for harm, one-off	The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Jun 30, 2023	D · Potential for harm, one-off	The facility did not dispose of garbage and refuse properly.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (7 → 4).

Year	Citations	Serious (G–L)	Worst severity that year
2023	12	0	E
2024	9	0	E
2025	4	1	G ▲
2026	4	0	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $8,407.

Date	Type	Amount / length
Dec 12, 2025	Fine	$8,407

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Texas avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.36	3.46	3.95	top 46% in Texas; bottom 29% in the U.S.
Registered Nurse hours	0.36	0.44	0.69	bottom 44% in Texas; bottom 17% in the U.S.
Weekend total nurse staffing	2.72	3.04	3.50	bottom 32% in Texas; bottom 17% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.20	0.34	0.48	bottom 23% in Texas; bottom 13% in the U.S.
Total nursing staff turnover (%)	38.1	55.3	45.8	top 16% in Texas; top 31% in the U.S.
RN turnover (%)	60.0	54.6	42.9	bottom 42% in Texas; bottom 22% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.38, RN 0.36, weekend 2.74. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Guadalupe County Hospital Board	Organization	5% or Greater Direct Ownership Interest	100%	04/01/2017
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	04/01/2017
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2016
Fowers, Matthew	Individual	Managing Control - Governing Body	NOT APPLICABLE	03/12/2019
Fowers, Matthew	Individual	Operational/Managerial Control	NOT APPLICABLE	03/12/2019
Fowers, Matthew	Individual	ADP of the SNF	NOT APPLICABLE	03/12/2019
Gann, Kody	Individual	Corporate Officer	NOT APPLICABLE	02/01/2021
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Krol, Michael	Individual	Managing Control - Governing Body	NOT APPLICABLE	05/01/2016
Krol, Michael	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2016
Krol, Michael	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2016
National Health Investors, INC.	Organization	ADP of the SNF	NOT APPLICABLE	04/01/2017
Texas Nhi Investors, LLC	Organization	ADP of the SNF	NOT APPLICABLE	04/01/2017
Treaty Healthcare, INC	Organization	Operational/Managerial Control	NOT APPLICABLE	04/01/2017
Treaty Healthcare, INC	Organization	ADP of the SNF	NOT APPLICABLE	10/07/2025

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"How do you keep residents' medical records accurate, complete, and secure?"
"Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
"How do you explain health changes and treatment options to residents and their families?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How soon after admission is a full assessment completed, and how are the findings shared with the family?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Marbridge Villa	8.3 mi	Manchaca, TX	★★★★☆	4/5
Brodie Ranch Nursing and Rehabilitation Center	9.3 mi	Austin, TX	★★★☆☆	3/5
Onion Creek Nursing and Rehabilitation Center	9.7 mi	Austin, TX	★☆☆☆☆	2/5
San Marcos Rehabilitation and Healthcare Center	10.1 mi	San Marcos, TX	★☆☆☆☆	1/5
Southpark Meadows Nursing and Rehabilitation Cente	11.2 mi	Austin, TX	★★☆☆☆	3/5
West Oaks Nursing and Rehabilitation Center	11.4 mi	Austin, TX	★★☆☆☆	2/5
Hays Nursing and Rehabilitation Center	12.0 mi	San Marcos, TX	★★★☆☆	3/5
Deer Creek Nursing and Rehabilitation	12.1 mi	Wimberley, TX	★☆☆☆☆	1/5
Cypress Healthcare and Rehabilitation Center	12.5 mi	San Marcos, TX	★☆☆☆☆	1/5
Brush Country Nursing and Rehabilitation	14.4 mi	Austin, TX	★☆☆☆☆	1/5
Stonebridge Health Rehab	14.7 mi	Austin, TX	★★★☆☆	3/5
Chisolm Trail Nursing and Rehabilitation Center	15.5 mi	Lockhart, TX	★★★☆☆	3/5

Compare this facility with the 3 closest →

All facilities in Kyle →

Facility data as of CMS processing date 2026-08-01. CCN 676272.

The Care File

Visit checklist — Legend Oaks Healthcare and Rehabilitation-Kyle

1640 Fairway, Kyle, TX 78640 · 5122681003

Health inspection rating 3/5 · CMS overall 3/5· Fines (3y): $8,407

Most serious findings on record:

▲ Dec 12, 2025 (F-0686, Actual harm, one-off): The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Questions for the administrator:

☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "How do you keep residents' medical records accurate, complete, and secure?"
☐ "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
☐ "How do you explain health changes and treatment options to residents and their families?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How soon after admission is a full assessment completed, and how are the findings shared with the family?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 676272 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)