Legend Oaks Healthcare And Rehabilitation-Kyle
Kyle, Hays County, Texas · CCN 676272 · For-profit (LLC) · part of The Ensign Group (342 facilities, chain average 3.2 stars)
CMS rates Legend Oaks Healthcare And Rehabilitation-Kyle 3 of 5 overall as of August 2026. 126 certified beds, 116 residents a day on average. 29 citations on record from the current inspection cycles, 1 involving actual harm; 1 fine totalling $8,407.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★☆☆ 3 of 5 |
|---|---|
| Health inspections | ★★★☆☆ 3 of 5 |
| Staffing | ★★☆☆☆ 2 of 5 |
| Quality measures | ★★★☆☆ 3 of 5 |
| Quality: long-stay / short-stay | 4 / 3 of 5 |
Staffing
| Total nurse staffing | 3.38222 hours per resident per day |
|---|---|
| Registered nurses | 0.36456 hours per resident per day |
| Weekend total | 2.73832 hours per resident per day |
| Nursing staff turnover | 38.1% (registered nurses 60%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-05-26 complaint survey |
Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-06-30 |
| 2026-05-26 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-06-30 |
| 2026-01-29 complaint survey |
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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-19 |
| 2026-01-29 complaint survey |
Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-19 |
| 2025-12-12 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 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. Resident Assessment and Care Planning Deficiencies · tag F0636 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-12-18 |
| 2025-12-12 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-12-15 |
| 2024-11-20 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-21 |
| 2024-11-20 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Resident Rights Deficiencies · tag F0550 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-09-06 |
| 2024-09-05 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Resident Rights Deficiencies · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-06 |
| 2024-09-05 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-06 |
| 2024-09-05 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · tag F0791 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-07 |
| 2024-09-05 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · tag F0919 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-06 |
| 2023-11-21 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-26 |
| 2023-08-10 complaint survey |
Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-08-22 |
| 2023-08-10 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-08-22 |
| 2023-08-10 complaint survey |
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. Pharmacy Service Deficiencies · tag F0758 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Resident Rights Deficiencies · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-28 |
| 2023-06-30 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-28 |
| 2023-06-30 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0698 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-28 |
| 2023-06-30 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · tag F0805 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-28 |
| 2023-06-30 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · tag F0814 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-28 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2025-12-12 | Fine | $8,407 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Guadalupe County Hospital Board Organization | 5% or greater direct ownership interest | 100% | 2017-04-01 |
| Ensign Services Inc. Organization | adp of the snf | — | 2016-05-01 |
| National Health Investors, Inc. Organization | adp of the snf | — | 2017-04-01 |
| Texas Nhi Investors, LLC Organization | adp of the snf | — | 2017-04-01 |
| Treaty Healthcare, Inc. Organization | adp of the snf | — | 2025-10-07 |
| Treaty Healthcare, Inc. Organization | operational/managerial control | — | 2017-04-01 |
| Fowers, Matthew Individual | adp of the snf | — | 2019-03-12 |
| Krol, Michael Individual | adp of the snf | — | 2016-05-01 |
| Burnam, Soon Individual | corporate officer | — | 2017-04-01 |
| Gann, Kody Individual | corporate officer | — | 2021-02-01 |
| Keetch, Chad Individual | corporate officer | — | 2011-03-01 |
| Fowers, Matthew Individual | managing control - governing body | — | 2019-03-12 |
| Krol, Michael Individual | managing control - governing body | — | 2016-05-01 |
| Fowers, Matthew Individual | operational/managerial control | — | 2019-03-12 |
| Krol, Michael Individual | operational/managerial control | — | 2016-05-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Legend Oaks Healthcare And Rehabilitation-Kyle.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Hays County.