About Legend Oaks Healthcare and Rehabilitation-Kyle
Legend Oaks Healthcare And Rehabilitation-kyle, located in Kyle, TX, is a for-profit organization that accepts Medicare and Medicaid.
Why Families Choose Legend Oaks Healthcare and Rehabilitation-Kyle
- Top Ranked: Ranked #9 out of 37 facilities within 25 miles.
Key Performance Indicators
- CMS Overall Rating 2 Stars
- Nursing Hours 3.21 hrs
- Safety Record Clean
Chain Affiliations & Network
This facility is part of the THE ENSIGN GROUP network. This chain operates 338 facilities.
Chain Performance Overview
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Nursing Staff Analysis
Staffing levels are a critical indicator of quality care. We analyze the daily hours of care provided by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs).
Below Average Staffing
Legend Oaks Healthcare and Rehabilitation-Kyle provides less care hours than the state average and less than the national average.
Registered Nurses (RN)
Licensed Practical Nurses
Certified Assistants
CMS Quality Ratings
| Category | Rating | Stars |
|---|---|---|
| Overall Rating | 2 |
|
| Health Inspection | 3 |
|
| Quality Measures | 3 |
|
| Staffing | 1 |
|
Health Inspection History
| Inspection Cycle | Score | Date |
|---|---|---|
| Cycle 1 (Most Recent) | 56 | Dec 12, 2025 |
| Weighted Average | 68 | Combined Score |
Detailed Quality Measures
Rates are from CMS quality measures (claims-based and MDS-based) for the reporting period ending May 01, 2026. Some measures may be omitted when CMS does not report a numeric rate for this facility.
Medicare claims-based measures
Typically includes short-stay outcomes, hospitalizations, and ED use from Medicare claims.
| Measure | Rate |
|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursi... (QM521) | 24.5% |
| Percentage of short-stay residents who had an outpatient emergency depar... (QM522) | 13.2% |
| Number of hospitalizations per 1000 long-stay resident days (QM551) | 2.0% |
| Number of outpatient emergency department visits per 1000 long-stay resi... (QM552) | 1.4% |
MDS-based measures
Resident assessment data; often used for long-stay care quality.
| Measure | Rate |
|---|---|
| Percentage of long-stay residents whose need for help with daily activit... (QM401) | 26.2% |
| Percentage of long-stay residents who lose too much weight (QM404) | 0.3% |
| Percentage of long-stay residents with a catheter inserted and left in t... (QM406) | 0.0% |
| Percentage of long-stay residents with a urinary tract infection (QM407) | 1.2% |
| Percentage of long-stay residents who have depressive symptoms (QM408) | 1.2% |
| Percentage of long-stay residents who were physically restrained (QM409) | 0.0% |
| Percentage of long-stay residents experiencing one or more falls with ma... (QM410) | 2.3% |
| Percentage of long-stay residents assessed and appropriately given the p... (QM415) | 97.2% |
| Percentage of short-stay residents assessed and appropriately given the... (QM430) | 93.2% |
| Percentage of short-stay residents who newly received an antipsychotic m... (QM434) | 0.2% |
| Percentage of long-stay residents whose ability to walk independently wo... (QM451) | 34.5% |
| Percentage of long-stay residents who received an antianxiety or hypnoti... (QM452) | 11.8% |
| Percentage of long-stay residents assessed and appropriately given the s... (QM454) | 87.6% |
| Percentage of short-stay residents who were assessed and appropriately g... (QM472) | 94.9% |
| Percentage of long-stay residents with pressure ulcers (QM479) | 3.3% |
| Percentage of long-stay residents with new or worsened bowel or bladder... (QM480) | 15.5% |
| Percentage of long-stay residents who received an antipsychotic medicati... (QM481) | 2.7% |
Complaints & Deficiencies
Complaint History by Year
This chart shows the number of complaints filed each year.
Summary:
- 2023: 6 complaints
- 2024: 3 complaints
- 2026: 2 complaints
- Total: 11 complaints on record
Recent Complaints (Since Jan 2023)
| Date | Description |
|---|---|
| Feb 19, 2026 | Ensure that residents are fully informed and understand their health status, care and treatments. |
| Feb 19, 2026 | 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. |
| Nov 21, 2024 | Provide and implement an infection prevention and control program. |
| Nov 21, 2024 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. |
| Jan 26, 2024 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. |
| Aug 22, 2023 | 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. |
| Aug 22, 2023 | Ensure services provided by the nursing facility meet professional standards of quality. |
| Aug 22, 2023 | Ensure that residents are fully informed and understand their health status, care and treatments. |
| Jun 22, 2023 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. |
| Jun 22, 2023 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. |
| Jun 22, 2023 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. |
Nearby Hospitals
ST DAVID'S SOUTH AUSTIN MEDICAL CENTER
AUSTIN, TX
ASCENSION SETON MEDICAL CENTER AUSTIN
AUSTIN, TX
ASCENSION SETON HAYS
KYLE, TX
CHRISTUS SANTA ROSA HOSPITAL-SAN MARCOS
SAN MARCOS, TX
ST DAVID'S MEDICAL CENTER
AUSTIN, TX
RESOLUTE HEALTH HOSPITAL
NEW BRAUNFELS, TX
BAYLOR SCOTT & WHITE MEDICAL CENTER- AUSTIN
AUSTIN, TX
THE HOSPITAL AT WESTLAKE MEDICAL CENTER
AUSTIN, TX
CROSS CREEK HOSPITAL
AUSTIN, TX
AUSTIN OAKS HOSPITAL
AUSTIN, TX
AUSTIN STATE HOSPITAL
AUSTIN, TX
DELL CHILDREN'S MEDICAL CENTER
AUSTIN, TX
ASCENSION SETON EDGAR B DAVIS
LULING, TX
ASCENSION SETON SOUTHWEST
AUSTIN, TX
NORTHWEST HILLS SURGICAL HOSPITAL
AUSTIN, TX
Owner & Operator Information
Business Entity
GUADALUPE COUNTY HOSPITAL BOARD
Ownership Structure
- GUADALUPE COUNTY HOSPITAL BOARD Direct: 100%
Management & Direction
- SOON BURNAM CORPORATE OFFICER
- ENSIGN SERVICES INC ADP OF THE SNF
- MATTHEW FOWERS MANAGING CONTROL - GOVERNING BODY
- MATTHEW FOWERS OPERATIONAL/MANAGERIAL CONTROL
- MATTHEW FOWERS ADP OF THE SNF
- KODY GANN CORPORATE OFFICER
- CHAD KEETCH CORPORATE OFFICER
- MICHAEL KROL MANAGING CONTROL - GOVERNING BODY
- MICHAEL KROL OPERATIONAL/MANAGERIAL CONTROL
- MICHAEL KROL ADP OF THE SNF
- NATIONAL HEALTH INVESTORS INC. ADP OF THE SNF
- TEXAS NHI INVESTORS LLC ADP OF THE SNF
- TREATY HEALTHCARE INC OPERATIONAL/MANAGERIAL CONTROL
- TREATY HEALTHCARE INC ADP OF THE SNF
Associated Doctors
Local Comparison
| Facility | Distance | Rating |
|---|---|---|
| Longhorn Village | N/A | 5 |
| Avir at Dripping Springs | N/A | 5 |
| Marbridge Villa | N/A | 5 |
| Sedona Trace Health and Wellness Center | N/A | 4 |
| The Arbour at Westminster Manor | N/A | 5 |
| Barton Valley Rehabilitation and Healthcare Center | N/A | 4 |
| Diversicare of Luling | N/A | 3 |
| Eden Home | N/A | 3 |
| Legend Oaks Healthcare and Rehabilitation-Kyle | N/A | 2 |
| Legend Oaks Healthcare and Rehabilitation - New Br | N/A | 3 |
Related Analysis
Best Nursing Homes in Kyle, TX
Compare Legend Oaks Healthcare and Rehabilitation-Kyle to the top-rated facilities in the area.
Ownership Details
Complete list of registered owners, including direct and indirect ownership.
Noted Deficiencies
Detailed history of deficiencies with descriptions and correction dates.
Nursing Hours Analysis
Detailed breakdown of staffing hours per resident by role.
Frequently Asked Questions
- Skilled Nursing Care: 24/7 medical supervision and complex medical treatments
- Long-term Residential Care: Assistance with daily living activities for extended stays
- Short-term Rehabilitation: Recovery services after hospital stays or surgeries
- Memory Care: Specialized programs for residents with dementia and Alzheimer's disease
- Level of care needed (skilled nursing vs. long-term care)
- Room type (private vs. semi-private)
- Insurance coverage (Medicare, Medicaid, private insurance)
- Length of stay and specific services required
For current rates and to discuss payment options, contact Legend Oaks Healthcare and Rehabilitation-Kyle directly at 5122681003. Their admissions team can help determine coverage and out-of-pocket expenses.
Environment & Cleanliness
- Overall cleanliness and odors
- Resident room conditions
- Common area maintenance
- Safety features and accessibility
Staff & Care Quality
- Staff-to-resident ratios
- How staff interact with residents
- Response time to resident needs
- Staff knowledge and professionalism
Ask to speak with current residents and their families, tour at different times of day, and review the facility's most recent inspection reports.