01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-12 | 8 | 2025-12-12 | 1 |
| Cycle 2 | 2024-09-05 | 9 | 2024-09-05 | 2 |
| Cycle 3 | 2023-06-30 | 12 | 2023-06-30 | 2 |
CMS CCN 6762722026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Legend Oaks Healthcare And Rehabilitation-Kyle
1640 Fairway · Kyle, TX 78640 · Hays County
Certified beds126CMS provider file
Recent citation rows34current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
34 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-05-26 · HEALTHF0695Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2026-06-30 · complaint2026-05-26 · HEALTHF0842Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2026-06-30 · complaint2026-01-29 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2026-02-19 · complaint2026-01-29 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-02-19 · complaint2025-12-12 · HEALTHF0636Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Correction field: Deficient, Provider has date of correction · 2025-12-182025-12-12 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-12-182025-12-12 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-12-152025-12-12 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-12-152025-12-12 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-12-172024-11-20 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-11-21 · complaint2024-11-20 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-11-21 · complaint2024-09-05 · HEALTHF0550Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-09-062024-09-05 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-09-062024-09-05 · HEALTHF0583Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2024-09-062024-09-05 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-09-062024-09-05 · HEALTHF0791Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Correction field: Deficient, Provider has date of correction · 2024-10-072024-09-05 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-09-062024-09-05 · HEALTHF0919Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Correction field: Deficient, Provider has date of correction · 2024-09-062024-09-05 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-02-142024-09-05 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-03-102023-11-21 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-01-26 · complaint2023-08-10 · HEALTHF0552Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2023-08-22 · complaint2023-08-10 · HEALTHF0658Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2023-08-22 · complaint2023-08-10 · HEALTHF0758Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-08-22 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-12-12 | Fine | $8,407 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- GUADALUPE COUNTY HOSPITAL BOARDOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/01/2017
- FOWERS, MATTHEWIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 03/12/2019
- KROL, MICHAELIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2016
- BURNAM, SOONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2017
- GANN, KODYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/01/2021
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2011
- TREATY HEALTHCARE, INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2017
- FOWERS, MATTHEWIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/12/2019
- KROL, MICHAELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2016
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2016
- NATIONAL HEALTH INVESTORS, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 04/01/2017
- TEXAS NHI INVESTORS, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/01/2017
- TREATY HEALTHCARE, INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/07/2025
- FOWERS, MATTHEWIndividual · ADP OF THE SNFNOT APPLICABLE · since 03/12/2019
- KROL, MICHAELIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/01/2016
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.38per resident day
RN hours0.36per resident day
Weekend nurse hours2.74per resident day
Staff turnover38.1%CMS reported field
06 / LOCAL RECORDS
Open the Texas ledger →Other published facilities nearby
No second facility in the same city met the directory rule.