Nursing homes › Texas › Legend Oaks Healthcare and Rehabilitation-Kyle
1640 Fairway, Kyle, TX 78640 · 5122681003 · 126 certified beds
Per CMS filings, this facility is affiliated with The Ensign Group, a group operating 346 facilities in 17 states. Group record: average rating 3.2/5, 33 abuse citation icons, 9 facilities on the Special Focus list, $7,179,329 in federal fines. This facility rates below its group average (3.2/5).
Total nurse staffing: 3.38 (Texas median: 3.27). RN hours: 0.36. Weekend total: 2.74. Nursing staff turnover: 38%.
All-time on record: 29 deficiency citations. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-05-26 | Provide safe and appropriate respiratory care for a resident when needed. | E | complaint | corrected 2026-06-30 |
| 2026-05-26 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E | complaint | corrected 2026-06-30 |
| 2026-01-29 | 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 | corrected 2026-02-19 |
| 2026-01-29 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | complaint | corrected 2026-02-19 |
| 2025-12-12 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Health | corrected 2025-12-18 |
| 2025-12-12 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Health | corrected 2025-12-15 |
| 2025-12-12 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D | Health | corrected 2025-12-18 |
| 2025-12-12 | Provide and implement an infection prevention and control program. | D | Health | corrected 2025-12-15 |
| 2024-11-20 | Provide and implement an infection prevention and control program. | E | complaint | corrected 2024-11-21 |
| 2024-11-20 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | complaint | corrected 2024-11-21 |
| 2024-09-05 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E | Health | corrected 2024-09-06 |
| 2024-09-05 | Keep residents' personal and medical records private and confidential. | E | Health | corrected 2024-09-06 |
| 2024-09-05 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2024-09-06 |
| 2024-09-05 | 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 | Health | corrected 2024-09-06 |
| 2024-09-05 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Health | corrected 2024-09-06 |
| 2024-09-05 | Provide or obtain dental services for each resident. | D | Health | corrected 2024-10-07 |
| 2024-09-05 | Make sure that a working call system is available in each resident's bathroom and bathing area. | D | Health | corrected 2024-09-06 |
| 2023-11-21 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | complaint | corrected 2024-01-26 |
| 2023-08-10 | Ensure that residents are fully informed and understand their health status, care and treatments. | E | complaint | corrected 2023-08-22 |
| 2023-08-10 | Ensure services provided by the nursing facility meet professional standards of quality. | E | complaint | corrected 2023-08-22 |
| 2023-08-10 | 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 | corrected 2023-08-22 |
| 2023-06-30 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Health | corrected 2023-07-28 |
| 2023-06-30 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2023-07-28 |
| 2023-06-30 | 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 | Health | corrected 2023-07-28 |
| 2023-06-30 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Health | corrected 2023-07-28 |
| 2023-06-30 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Health | corrected 2023-07-28 |
| 2023-06-30 | 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 | Health | corrected 2023-07-28 |
| 2023-06-30 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D | Health | corrected 2023-07-28 |
| 2023-06-30 | Dispose of garbage and refuse properly. | D | Health | corrected 2023-07-28 |
| Date | Type | Amount |
|---|---|---|
| 2025-12-12 | Fine | $8,278 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| GUADALUPE COUNTY HOSPITAL BOARD | 5% Or Greater Direct Ownership Interest | Organization | 100% | since 04/01/2017 |
| FOWERS, MATTHEW | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 03/12/2019 |
| KROL, MICHAEL | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 05/01/2016 |
| BURNAM, SOON | Corporate Officer | Individual | NOT APPLICABLE | since 04/01/2017 |
| GANN, KODY | Corporate Officer | Individual | NOT APPLICABLE | since 02/01/2021 |
| KEETCH, CHAD | Corporate Officer | Individual | NOT APPLICABLE | since 03/01/2011 |
| TREATY HEALTHCARE, INC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 04/01/2017 |
| FOWERS, MATTHEW | Operational/Managerial Control | Individual | NOT APPLICABLE | since 03/12/2019 |
| KROL, MICHAEL | Operational/Managerial Control | Individual | NOT APPLICABLE | since 05/01/2016 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 676272. Corrections: data@carerecords.org.