Texas ›New Braunfels

Legend Oaks Healthcare and Rehabilitation - New Br

2468 Fm 1101, New Braunfels, TX 78130 · Comal County · 126 certified beds · avg 115 residents/day · certified since Oct 16, 2015

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

3/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
3.29
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.

All citations in the current public record (38)

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

DateSeverityWhat the facility was cited for
May 20, 2026E · Potential for harm, repeatedThe 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.
May 20, 2026D · Potential for harm, one-offThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
May 20, 2026D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 20, 2026D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
May 20, 2026D · Potential for harm, one-offThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 20, 2026D · Potential for harm, one-offThe facility did not have a policy covering how food brought in by family and visitors is used and stored safely.
May 20, 2026D · Potential for harm, one-offThe facility did not dispose of garbage and refuse properly.
Apr 29, 2026D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Sep 10, 2025E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Sep 10, 2025D · Potential for harm, one-offThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. · from a complaint
Mar 28, 2025E · Potential for harm, repeatedThe 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.
Mar 28, 2025E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Mar 28, 2025E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 28, 2025D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Mar 28, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Mar 28, 2025D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Mar 28, 2025D · Potential for harm, one-offThe facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Mar 28, 2025D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Mar 28, 2025D · Potential for harm, one-offThe facility did not develop, carry out, or maintain an effective training program for all new and existing staff members.
Mar 28, 2025D · Potential for harm, one-offThe facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents.
Mar 28, 2025D · Potential for harm, one-offThe facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation.
Mar 28, 2025D · Potential for harm, one-offThe facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better.
Mar 28, 2025D · Potential for harm, one-offThe facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program.
Mar 28, 2025D · Potential for harm, one-offThe facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated.
Mar 28, 2025D · Potential for harm, one-offThe facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs.
Feb 6, 2025D · Potential for harm, one-offThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Feb 6, 2025D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
Feb 6, 2025D · Potential for harm, one-offThe 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
Feb 6, 2025D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Aug 3, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Aug 3, 2024D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Feb 29, 2024D · Potential for harm, one-offThe 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. · from a complaint
Jan 27, 2024D · Potential for harm, one-offThe 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
Jan 27, 2024D · Potential for harm, one-offThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Jan 27, 2024D · Potential for harm, one-offThe 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.
Jan 27, 2024D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Jan 27, 2024D · Potential for harm, one-offThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jan 20, 2024D · Potential for harm, one-offThe 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

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (15 → 7).

YearCitationsSerious (G–L)Worst severity that year
202490D
2025210E
202680E

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)

No fines or payment denials in the published 3-year window.

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

MeasureThis facilityTexas avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.293.463.95bottom 48% in Texas; bottom 26% in the U.S.
Registered Nurse hours0.450.440.69top 35% in Texas; bottom 30% in the U.S.
Weekend total nurse staffing2.863.043.50bottom 44% in Texas; bottom 24% in the U.S.
Weekend RN hours (not acuity-adjusted)0.420.340.48top 23% in Texas; top 45% in the U.S.
Total nursing staff turnover (%)49.555.345.8top 43% in Texas; bottom 38% in the U.S.
RN turnover (%)53.854.642.9bottom 50% in Texas; bottom 30% 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 3.30, RN 0.45, weekend 2.87. 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: 4/5 · long-stay residents: 5/5 · short-stay residents: 2/5

Who owns this facility

Government - Hospital district

Owner / managerTypeRoleStakeSince
Guadalupe County Hospital BoardOrganization5% or Greater Direct Ownership Interest100%04/01/2019
Burnam, SoonIndividualCorporate OfficerNOT APPLICABLE04/01/2019
Ensign Services INCOrganizationADP of the SNFNOT APPLICABLE05/01/2016
Gann, KodyIndividualCorporate OfficerNOT APPLICABLE02/01/2021
Keetch, ChadIndividualCorporate OfficerNOT APPLICABLE03/01/2011
National Health Investors, INC.OrganizationADP of the SNFNOT APPLICABLE04/01/2019
Newsome, GarrettIndividualManaging Control - Governing BodyNOT APPLICABLE11/12/2020
Newsome, GarrettIndividualOperational/Managerial ControlNOT APPLICABLE11/12/2020
Newsome, GarrettIndividualADP of the SNFNOT APPLICABLE11/12/2020
Riverwalk Healthcare INCOrganizationOperational/Managerial ControlNOT APPLICABLE04/01/2019
Riverwalk Healthcare INCOrganizationADP of the SNFNOT APPLICABLE10/07/2025
Texas Nhi Investors, LLCOrganizationADP of the SNFNOT APPLICABLE04/01/2019
Yu, HaoranIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2017
Yu, HaoranIndividualOperational/Managerial ControlNOT APPLICABLE11/01/2017
Yu, HaoranIndividualADP of the SNFNOT APPLICABLE11/01/2017

Questions to ask on your visit

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

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Avir at New Braunfels1.0 miNew Braunfels, TX★☆☆☆☆1/5abuse
Sundance Inn Health Center2.0 miNew Braunfels, TX★★☆☆☆2/5abuse
Eden Home3.9 miNew Braunfels, TX★★★☆☆3/5
Kirkwood Manor5.8 miNew Braunfels, TX★★☆☆☆2/5
Cypress Healthcare and Rehabilitation Center11.0 miSan Marcos, TX★☆☆☆☆1/5
Hays Nursing and Rehabilitation Center11.6 miSan Marcos, TX★★★☆☆3/5
Avir at Walnut Springs11.6 miSeguin, TX★★★★☆4/5
Avir at Seguin12.8 miSeguin, TX★☆☆☆☆2/5abuse
Guadalupe Valley Nursing and Rehabilitation Center13.0 miSeguin, TX★★☆☆☆2/5
Windsor Nursing and Rehabilitation Center of Segui13.0 miSeguin, TX★★☆☆☆3/5
River Bend Healthcare13.1 miSeguin, TX★☆☆☆☆2/5
San Marcos Rehabilitation and Healthcare Center13.2 miSan Marcos, TX★☆☆☆☆1/5

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Facility data as of CMS processing date 2026-08-01. CCN 676392.