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Legend Oaks Healthcare And Rehabilitation-Kyle

1640 Fairway, Kyle, TX 78640
5122681003
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Overall CMS Rating

4.0/5

vs State Average: 2.8 stars

3.0/5

Health Inspections

vs State Average: 2.8/5

2.0/5

Staffing Level

vs State Average: 2.1/5

5.0/5

Quality Measures

vs State Average: 3.8/5

1 penalties in last 3 years
Penalties
vs State Average: 1.8 penalties

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Ratings Deep Dive

Score
3.0
State Average
2.8
National Average
2.8
5 Deficiencies found in last inspections
1 Penalties in last 3 years
1 Fines issued
Citation Date Description Severity
Nov 20, 2024 Provide and implement an infection prevention and control program. E
Nov 20, 2024 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. D
Sep 5, 2024 Keep residents' personal and medical records private and confidential. E
Sep 5, 2024 Provide or obtain dental services for each resident. D
Sep 5, 2024 Provide care and assistance to perform activities of daily living for any resident who is unable. D
Score
2.0
State Average
2.1
National Average
2.9
0.3 RN Hours / Resident / Day
3.3 Total Nurse Hours / Resident / Day
54.5% RN Turnover Rate
Score
5.0
State Average
3.8
National Average
3.6
4.0 Long-Stay QM Rating
5.0 Short-Stay QM Rating
112.4 Avg Residents Per Day
Measure Score Type
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay
Percentage of long-stay residents who lose too much weight Long Stay
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay
Percentage of long-stay residents with a urinary tract infection Long Stay
Percentage of long-stay residents who have depressive symptoms Long Stay
Percentage of long-stay residents who were physically restrained Long Stay
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay

Ownership & Compliance

Ownership Info
5% OR GREATER DIRECT OWNERSHIP INTEREST GUADALUPE COUNTY HOSPITAL BOARD
OPERATIONAL/MANAGERIAL CONTROL TREATY HEALTHCARE, INC
OPERATIONAL/MANAGERIAL CONTROL FOWERS, MATTHEW
OPERATIONAL/MANAGERIAL CONTROL KROL, MICHAEL
CORPORATE OFFICER BURNAM, SOON
CORPORATE OFFICER GANN, KODY
CORPORATE OFFICER KEETCH, CHAD
Recent Penalties
Date Type Fine
Dec 12, 2025 Fine $12,735

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