Cycle 1
Health 2024-09-05 · Fire 2024-09-05
9 health deficiencies
Top issue: Resident Rights (5 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Kyle, TX
Legend Oaks Healthcare and Rehabilitation-Kyle
4-star overall rating with 3-star inspections with $12,735 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1640 Fairway, Kyle, TX
(512) 268-1003
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2011-02-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.30
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.44
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,794
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9956
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.53
Baseline 19.95% · Performance 18.87% · Measure score 5.53 · Achievement 5.53 · Improvement 3.20
Healthcare-associated infections
3.48
Baseline 4.96% · Performance 6.79% · Measure score 3.48 · Achievement 3.48 · Improvement 0
Total nurse turnover
7.42
Baseline 62.37% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 7.24
Adjusted total nurse staffing
0.63
Baseline 3.12 hours · Performance 3.26 hours · Measure score 0.63 · Achievement 0.63 · Improvement 0.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.03% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 233 · Observed rate 6.44% · Lower 95% interval 6.38% |
| Discharge to community | 60.59% |
50.57%
10 pts better
|
Better than the National Rate · Eligible stays 202 · Observed rate 57.43% · Lower 95% interval 53.96% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 125 · Denominator 130 |
| Falls with major injury | 0.77% |
0.77%
About the same
|
Numerator 1 · Denominator 130 |
| Discharge self-care score | 56.6% |
53.69%
2.9 pts better
|
Numerator 60 · Denominator 106 |
| Discharge mobility score | 41.51% |
50.94%
9.4 pts worse
|
Numerator 44 · Denominator 106 |
| Pressure ulcers or injuries, new or worsened | 5.38% |
2.29%
3.1 pts worse
|
Numerator 7 · Denominator 130 · Adjusted rate 5.36% |
| Healthcare-associated infections requiring hospitalization | 6.8% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 5.38% · Lower 95% interval 4.31% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 168 |
| Staff flu vaccination coverage | 9.46% |
42%
32.5 pts worse
|
Numerator 21 · Denominator 222 |
| Discharge function score | 61.32% |
56.45%
4.9 pts better
|
Numerator 65 · Denominator 106 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 68 · Denominator 68 |
| Resident COVID-19 vaccinations up to date | 9.8% |
25.2%
15.4 pts worse
|
Numerator 5 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.1
1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
97.1%
0.3 pts worse
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 95.3% · Q3 95.6% · Q4 98.9% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.6% |
97.9%
10.3 pts worse
|
95.5%
7.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 2.2% · Q4 2.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
2.7%
1.7 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.3% · Q4 1.2% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
3.3%
2.7 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.9% |
18.9%
8 pts better
|
19.6%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 12.3% · Q3 9.2% · Q4 12.6% · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.3% |
10.8%
7.5 pts better
|
16.7%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.5% · Q3 2.7% · Q4 5.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 35.5% |
15.4%
20.1 pts worse
|
16.3%
19.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.1% · Q4 36.3% · 4Q avg 35.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.3% |
16.1%
17.2 pts worse
|
14.9%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.1% · Q2 30.7% · Q3 25.3% · Q4 33.3% · 4Q avg 33.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
0.8%
0.4 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.0% |
15.0%
3 pts worse
|
19.8%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 17.6% · Q3 12.6% · Q4 20.0% · 4Q avg 18.0% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.2%
1.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 4.9% · Q3 4.4% · Q4 2.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
89.7%
3.7 pts better
|
81.7%
11.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 94.8% · Q3 93.8% · Q4 93.4% · 4Q avg 93.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
12.0%
2.3 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 9.8% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.9% |
88.0%
6.9 pts better
|
79.7%
15.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
25.9%
7.4 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 17.4% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-30 · Fire 2023-06-30
10 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-04-28 · Fire 2022-04-28
7 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-14
D · Potential for more than minimal harm
2024-09-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-10
D · Potential for more than minimal harm
2023-06-30
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-06-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-29
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2026-02-19
D · Potential for more than minimal harm
2026-01-29
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-02-19
E · Potential for more than minimal harm
2024-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-11-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-09-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-06
E · Potential for more than minimal harm
2024-09-05
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-09-06
E · Potential for more than minimal harm
2024-09-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-09-05
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-09-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-09-05
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-09-05
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-09-06
D · Potential for more than minimal harm
2023-11-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-26
E · Potential for more than minimal harm
2023-08-10
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-08-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-08-10
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-06-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-30
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-30
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-30
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-30
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-30
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-13
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-06-22
E · Potential for more than minimal harm
2023-06-13
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-06-22
E · Potential for more than minimal harm
2023-06-13
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-06-22
Penalties and ownership
What sits behind the stars
$12,735
2025-12-12
Fine
Fine · fine $12,735
Fine
Ownership
Guadalupe County Hospital Board
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Fowers, Matthew
Operational/Managerial Control · Individual
Gann, Kody
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Krol, Michael
Operational/Managerial Control · Individual
Treaty Healthcare, Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Marbridge Villa
Manchaca, TX
5-star overall rating with 4-star inspections with $45,778 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Brodie Ranch Nursing And Rehabilitation Center
Austin, TX
3-star overall rating with 3-star inspections with $235,557 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Onion Creek Nursing And Rehabilitation Center
Austin, TX
1-star overall rating with 1-star inspections with $51,337 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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