NursingHomeGrade

Legend Oaks Healthcare and Rehabilitation-Kyle

1640 Fairway, Kyle, TX 78640

Operator

GUADALUPE COUNTY HOSPITAL BOARD · 26 facilities

Provider number (CCN)
676272
Certification
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified beds
126
Phone
(512) 268-1003
CMS data as of
July 1, 2026
D

What the records show

CMS rates Legend Oaks Healthcare and Rehabilitation-Kyle 3 out of 5 stars overall, with 3 of 5 for health inspections, 2 of 5 for staffing, 3 of 5 for quality measures. Federal inspectors cited 29 health deficiencies across the last three survey cycles, most recently surveyed in 2025, 1 at actual-harm level or higher, 2 still recorded as uncorrected. CMS enforcement records list 1 fine totalling $8,278.

Facility Assessment 2 federal violations at this facility remain unresolved. Inspectors recorded 1 citation at the actual-harm level or worse in the last three survey cycles. This facility is operated by GUADALUPE COUNTY HOSPITAL BOARD, which scores 18 points below the national average. This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.

Reviews, Ratings and Official Records

This page reviews Legend Oaks Healthcare and Rehabilitation-Kyle using federal government records — CMS star ratings, health-inspection findings, staffing data and enforcement actions. NursingHomeGrade does not collect, host or publish resident or family testimonials, and no star rating below is a consumer review score.

Below the repealed 0.55 hr RN benchmark — elevated deficiency count.

Ratings and Grade Breakdown

RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
 0.36 — Below the repealed 0.55 hr benchmark

The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
Total 29
Outstanding 2
Actual harm or worse (G–L) 1
CMS Ratings
Federal five-star ratings published by CMS. These are regulatory ratings, not consumer review scores.
Overall: ★★★☆☆ (3/5)
Health inspection: ★★★☆☆ (3/5)
Quality: ★★★☆☆ (3/5)
Staffing: ★★☆☆☆ (2/5)
NursingHomeGrade Score
 39/100

Loaded into NursingHomeGrade on August 7, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.

CMS scores each facility from one to five stars — one is in the bottom fifth of facilities in its state on health inspections, five is in the top tenth. Our own A–F grade is a separate 0–100 score built from staffing hours, inspection citations, and the severity and correction status of those citations, weighted as described in our grading methodology.

Staffing Compared With State and National Levels

This facility0.36 hrs
TX median0.38 hrs
National average0.69 hrs

Registered nurse turnover: 60.0% · Total nursing staff turnover: 38.1%

Staffing figures are the values CMS published in its file processed July 1, 2026, drawn from payroll-based journal reporting.

Inspection Records Covered

Source records: CMS Care Compare profile for provider 676272 ↗ · the federal files we load and when.

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

1 actual harm issue found among 29 total deficiencies. 27 corrected. — 2 still outstanding

Most recent inspection (December 12, 2025)

E Potential harm — pattern F0695 Status: Outstanding — Plan Filed

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has plan of correction, corrected June 30, 2026

E Potential harm — pattern F0842 Status: Outstanding — Plan Filed

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 — Deficient, Provider has plan of correction, corrected June 30, 2026

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2025

F Potential harm — widespread F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2025

G Actual harm — isolated F0686 Status: Corrected

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0636 Status: Corrected

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 — Deficient, Provider has date of correction, corrected December 18, 2025

E Potential harm — pattern F0584 Status: Corrected

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 — Deficient, Provider has date of correction, corrected February 19, 2026

D Potential harm — isolated F0552 Status: Corrected

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2026

Inspection cycle 2 (September 5, 2024)

D Potential harm — isolated F0919 Status: Corrected

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected September 6, 2024

D Potential harm — isolated F0600 Status: Corrected

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 — Deficient, Provider has date of correction, corrected November 21, 2024

E Potential harm — pattern F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 21, 2024

E Potential harm — pattern F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 6, 2024

D Potential harm — isolated F0677 Status: Corrected

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 6, 2024

D Potential harm — isolated F0791 Status: Corrected

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 7, 2024

E Potential harm — pattern F0550 Status: Corrected

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 6, 2024

E Potential harm — pattern F0583 Status: Corrected

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 6, 2024

D Potential harm — isolated F0578 Status: Corrected

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 — Deficient, Provider has date of correction, corrected September 6, 2024

Inspection cycle 3 (November 21, 2023)

D Potential harm — isolated F0609 Status: Corrected

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected January 26, 2024

E Potential harm — pattern F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023

D Potential harm — isolated F0805 Status: Corrected

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023

D Potential harm — isolated F0814 Status: Corrected

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023

E Potential harm — pattern F0758 Status: Corrected

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 — Deficient, Provider has date of correction, corrected August 22, 2023

E Potential harm — pattern F0755 Status: Corrected

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023

D Potential harm — isolated F0758 Status: Corrected

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 — Deficient, Provider has date of correction, corrected July 28, 2023

D Potential harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023

D Potential harm — isolated F0698 Status: Corrected

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023

E Potential harm — pattern F0658 Status: Corrected

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 22, 2023

E Potential harm — pattern F0552 Status: Corrected

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 22, 2023

D Potential harm — isolated F0578 Status: Corrected

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 — Deficient, Provider has date of correction, corrected July 28, 2023

Fines and Enforcement Actions

Penalties CMS has imposed on this facility. A fine is a civil money penalty; a payment denial suspends Medicare or Medicaid payment for new admissions.

Date Action Amount or length
December 12, 2025 Fine $8,278

1 fine totalling $8,278.

Source: CMS Penalties file (dataset g6vv-u9sr).

Ownership and Contact Information

Facility name
Legend Oaks Healthcare and Rehabilitation-Kyle
Legal business name
GUADALUPE COUNTY HOSPITAL BOARD
Address
1640 Fairway, Kyle, TX 78640
Phone
(512) 268-1003
Provider number (CCN)
676272
Ownership type
For profit - Limited Liability company
Operator
GUADALUPE COUNTY HOSPITAL BOARD · 26 facilities
Medicare/Medicaid certified since
February 8, 2011
Official record
CMS Care Compare profile ↗
Details verified against CMS data dated
July 1, 2026

The federal nursing-home files publish no email address for certified facilities, so none is listed here. We do not guess or construct contact addresses. Contact details above are reproduced from CMS Provider Information; call the facility to confirm before relying on them.

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Sources and Methodology

The NursingHomeGrade score is our own calculation from these federal files — it is not a CMS rating and not a consumer review score. See exactly how the score is calculated · full methodology · source files and load dates.

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