Legend Oaks Healthcare and Rehabilitation-Kyle
1640 Fairway, Kyle, TX 78640
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Follow this homeLegend Oaks Healthcare and Rehabilitation-Kyle is a nursing home in Kyle, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating3 of 5
- Last standard health inspectionDecember 12, 2025 (10 months ago)
- Health citations since June 30, 202326 (Texas average 28)
- Fines in the past three years1, $8,407 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 8, 2026
Fine
CMS changed the fine from December 12, 2025 from $8,278 to $8,407.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of June 24, 2026
Fine
CMS changed the fine from December 12, 2025 from $12,735 to $8,278.
Health inspection on May 26, 2026
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0695. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on June 30, 2026.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on June 30, 2026.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 3 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Health inspection on January 29, 2026
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on February 19, 2026.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on February 19, 2026.
Health inspection on December 12, 2025
4 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
107 of 1,177 Texas homes (9%) got a citation at the actual harm level in 2025.
CMS fine of $8,407 on December 12, 2025.
Show the 4 citations
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on December 18, 2025.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for F0812 3 times since 2023.
Citation F0636. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS lists it as corrected on December 18, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for F0880 2 times since 2024.
Fire safety inspection on December 12, 2025
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on December 17, 2025.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on November 20, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 21, 2024.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on November 21, 2024.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Health inspection on September 5, 2024
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on September 6, 2024.
Citation F0583. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on September 6, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 6, 2024.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 6, 2024.
CMS has cited this home for F0578 2 times since 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on September 6, 2024.
Citation F0791. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain dental services for each resident.
CMS lists it as corrected on October 7, 2024.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on September 6, 2024.
Fire safety inspection on September 5, 2024
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on February 14, 2025.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 10, 2025.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Health inspection on November 21, 2023
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on January 26, 2024.
Health inspection on June 30, 2023
8 citationsCMS lists this as a standard inspection.
Show the 8 citations
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on July 28, 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 28, 2023.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 28, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 28, 2023.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on July 28, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 28, 2023.
Citation F0805. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on July 28, 2023.
Citation F0814. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on July 28, 2023.
Fire safety inspection on June 30, 2023
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0781. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on June 29, 2023.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on June 29, 2023.
CMS star ratings
- 3 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (512) 268-1003
- Last standard health inspection
- December 12, 2025 (10 months ago)
- Certified beds
- 126
- Residents per day, on average
- 114.8
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Guadalupe County Hospital Board
- Chain
- The Ensign Group
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Texas average (26 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- GUADALUPE COUNTY HOSPITAL BOARD5% or greater direct ownership interest · 100% · since 04/01/2017
- TREATY HEALTHCARE, INCOperational/managerial control · not applicable · since 04/01/2017
- FOWERS, MATTHEWOperational/managerial control · not applicable · since 03/12/2019
- KROL, MICHAELOperational/managerial control · not applicable · since 05/01/2016
Questions
When was Legend Oaks Healthcare and Rehabilitation-Kyle last inspected?
CMS lists December 12, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Legend Oaks Healthcare and Rehabilitation-Kyle have?
CMS lists 26 health citations since June 30, 2023. CMS also calls these deficiencies.
Has Legend Oaks Healthcare and Rehabilitation-Kyle been fined?
CMS lists 1 fine in the past three years, $8,407 in total.
What is the CMS star rating of Legend Oaks Healthcare and Rehabilitation-Kyle?
Its CMS overall star rating is 3 of 5.
Is Legend Oaks Healthcare and Rehabilitation-Kyle a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.