For profit - Limited Liability company · 126 certified beds · CMS number 676272
Legend Oaks Healthcare and Rehabilitation-Kyle, Kyle, TX
CMS records 26 health deficiencies at Legend Oaks Healthcare and Rehabilitation-Kyle in Kyle, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Dec 12, 2025. The highest severity cited is G (actual harm (not immediate jeopardy)). CMS lists 1 fine totaling $8,407 in the last three years.
- 26deficiencies, 3 cycles (TX median 25)
- 8in the latest cycle (TX median 8)
- Ghighest severity · Actual harm
- $8,407fines, last 3 years
- 3CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Legend Oaks Healthcare and Rehabilitation-Kyle as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Legend Oaks Healthcare and Rehabilitation-Kyle may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (8 deficiencies)
Standard inspection Dec 12, 2025. CMS counts 8 health deficiencies and 1 fire safety deficiency in this cycle.
May 26, 2026 · Complaint inspection
2 deficiencies, highest E
F842 · Complete, confidential medical records
Requirement cited (CMS): Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jun 30, 2026
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jun 30, 2026
Jan 29, 2026 · Complaint inspection
2 deficiencies, highest E
F584 · Safe, clean, homelike surroundings
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 19, 2026
F552 · Being informed about health and treatment
Requirement cited (CMS): Ensure that residents are fully informed and understand their health status, care and treatments.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 19, 2026
Dec 12, 2025 · Standard inspection
4 deficiencies, highest G
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 15, 2025
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Dec 15, 2025
F686 · Pressure ulcer prevention and care
Requirement cited (CMS): Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Severity
- G Actual harm (not immediate jeopardy), isolated
- Status
- Correction date Dec 18, 2025
F636 · Full assessment at admission and yearly
Requirement cited (CMS): Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 18, 2025
Previous cycle: 9 deficiencies (standard inspection Sep 5, 2024)
Standard inspection Sep 5, 2024. CMS counts 9 health deficiencies and 2 fire safety deficiencies in this cycle.
Nov 20, 2024 · Complaint inspection
2 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Nov 21, 2024
F600 · Freedom from abuse and neglect
Requirement cited (CMS): Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Nov 21, 2024
Sep 5, 2024 · Standard inspection
7 deficiencies, highest E
F919 · Working call system
Requirement cited (CMS): Make sure that a working call system is available in each resident's bathroom and bathing area.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 6, 2024
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Sep 6, 2024
F791 · Dental services in Medicaid nursing facilities
Requirement cited (CMS): Provide or obtain dental services for each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 7, 2024
F677 · Help with daily care
Requirement cited (CMS): Provide care and assistance to perform activities of daily living for any resident who is unable.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 6, 2024
F583 · Personal privacy and confidential records
Requirement cited (CMS): Keep residents' personal and medical records private and confidential.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Sep 6, 2024
F578 · Refusing treatment and advance directives
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 6, 2024
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Sep 6, 2024
Earlier cycle: 9 deficiencies (standard inspection Jun 30, 2023)
Standard inspection Jun 30, 2023. CMS counts 9 health deficiencies and 2 fire safety deficiencies in this cycle.
Nov 21, 2023 · Complaint inspection
1 deficiency, highest D
F609 · Reporting suspected abuse and crimes
Requirement cited (CMS): Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 26, 2024
Jun 30, 2023 · Standard inspection
8 deficiencies, highest E
F814 · Garbage disposal
Requirement cited (CMS): Dispose of garbage and refuse properly.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 28, 2023
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jul 28, 2023
F805 · Food prepared for individual needs
Requirement cited (CMS): Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 28, 2023
F758 · Psychotropic drug safeguards
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 28, 2023
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jul 28, 2023
F698 · Dialysis care
Requirement cited (CMS): Provide safe, appropriate dialysis care/services for a resident who requires such services.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 28, 2023
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 28, 2023
F578 · Refusing treatment and advance directives
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 28, 2023
Tags cited in more than one inspection
3 tags cited on more than one inspection date at Legend Oaks Healthcare and Rehabilitation-Kyle; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F812 Food safety and sanitation | 3 | Dec 12, 2025; Sep 5, 2024; Jun 30, 2023 |
| F578 Refusing treatment and advance directives | 2 | Sep 5, 2024; Jun 30, 2023 |
| F880 Infection prevention and control program | 2 | Dec 12, 2025; Nov 20, 2024 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| Dec 12, 2025 | Fine | $8,407 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 3.38 h (about the same as the Texas median of 3.27 h)
- RN hours per resident per day
- 0.36 h (about the same as the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 2.74 h
- Nursing staff turnover
- 38.1% (Texas median 52.1%)
- Administrators who left
- 0
- CMS overall rating
- 3 of 5
- Health inspection rating
- 3 of 5
- Staffing rating
- 2 of 5
- Quality measure rating
- 3 of 5
CMS figures for Legend Oaks Healthcare and Rehabilitation-Kyle, copied as published; Texas medians are ours.
Facility details
- Address
- 1640 Fairway, Kyle, TX 78640
- Phone
- (512) 268-1003
- County
- Hays
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Chain (CMS)
- The Ensign Group
- Certified beds
- 126
- Average residents per day
- 115.9
- In Medicare/Medicaid since
- Feb 8, 2011
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- When was the kitchen last inspected, and how are food temperatures checked? (F812, cited 3 times)
- How does the home record and follow a resident's advance directive? (F578, cited 2 times)
- How do staff track and report infections among residents? (F880, cited 2 times)
- How do staff learn about and respect each resident's personal routines and choices? (F550, cited 1 time)
Other nursing homes in Kyle and the same chain
- The Eden of Las Colinas
Irving · 65 deficiencies - Northeast Rehabilitation and Healthcare Center
San Antonio · 57 deficiencies - Westpark Rehabilitation and Living
Euless · 54 deficiencies - Park Village Healthcare and Rehabilitation
DeSoto · 52 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.