Cycle 1
Health 2025-03-28 · Fire 2025-03-28
17 health deficiencies
Top issue: Administration (5 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
New Braunfels, TX
Legend Oaks Healthcare And Rehabilitation - New Br
3-star overall rating with 3-star inspections with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2468 Fm 1101, New Braunfels, TX
(830) 420-6500
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
107
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2015-10-16
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
0.37
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,674
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.93% · Performance 21.45% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.39% · Performance 7.89% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.79
Baseline 54.55% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 4.40
Adjusted total nurse staffing
0.50
Baseline 3 hours · Performance 3.22 hours · Measure score 0.50 · Achievement 0.50 · Improvement 0.30
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.23% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 161 · Observed rate 11.8% · Lower 95% interval 8.16% |
| Discharge to community | 46.73% |
50.57%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 42.65% · Lower 95% interval 39.67% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.97% |
95.27%
3.7 pts better
|
Numerator 192 · Denominator 194 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 194 |
| Discharge self-care score | 47.5% |
53.69%
6.2 pts worse
|
Numerator 38 · Denominator 80 |
| Discharge mobility score | 35% |
50.94%
15.9 pts worse
|
Numerator 28 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 4.64% |
2.29%
2.3 pts worse
|
Numerator 9 · Denominator 194 · Adjusted rate 5.27% |
| Healthcare-associated infections requiring hospitalization | 7.89% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 123 · Observed rate 8.13% · Lower 95% interval 5.51% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 174 |
| Staff flu vaccination coverage | 44.12% |
42%
2.1 pts better
|
Numerator 90 · Denominator 204 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 40 · Denominator 80 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 69 · Denominator 69 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 91 · Denominator 91 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 104 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
97.1%
1.5 pts worse
|
93.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 96.0% · Q3 95.8% · Q4 91.8% · 4Q avg 95.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.3%
1.1 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 6.7% · Q3 5.6% · Q4 2.7% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
2.7%
0.5 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.9% · Q3 0.0% · Q4 4.5% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
3.3%
2.5 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.9% |
18.9%
1 pts worse
|
19.6%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 20.6% · Q3 16.7% · Q4 21.4% · 4Q avg 19.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.8% |
10.8%
5 pts better
|
16.7%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.6% · Q3 5.5% · Q4 8.3% · 4Q avg 5.8% · 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 | 17.3% |
15.4%
1.9 pts worse
|
16.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 22.3% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.4% |
16.1%
7.3 pts worse
|
14.9%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 19.7% · Q3 22.6% · Q4 26.6% · 4Q avg 23.4% · 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 | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.5% |
15.0%
3.5 pts worse
|
19.8%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 19.2% · Q3 17.4% · Q4 11.4% · 4Q avg 18.5% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.2%
1.6 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.8% · Q3 4.1% · Q4 1.1% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.6% |
89.7%
6.1 pts worse
|
81.7%
1.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.4% · Q2 91.6% · Q3 82.2% · Q4 71.5% · 4Q avg 83.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
12.0%
0.1 pts worse
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 11.9% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.0% · Q3 1.4% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.7% |
88.0%
0.7 pts better
|
79.7%
9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
25.9%
0.4 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 25.0% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-27 · Fire 2024-01-27
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-11-18 · Fire 2022-11-18
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-31
F · Potential for more than minimal harm
2024-01-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-04
F · Potential for more than minimal harm
2022-11-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-12
F · Potential for more than minimal harm
2022-11-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-09-10
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-09-15
E · Potential for more than minimal harm
2025-03-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-02
E · Potential for more than minimal harm
2025-03-28
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 2025-04-02
E · Potential for more than minimal harm
2025-03-28
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 2025-03-29
D · Potential for more than minimal harm
2025-03-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-28
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-28
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-28
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-28
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-28
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-28
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-28
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-28
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-02-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-02-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-02-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-02-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-07
D · Potential for more than minimal harm
2024-08-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-04
D · Potential for more than minimal harm
2024-08-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-04
D · Potential for more than minimal harm
2024-02-29
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 2024-02-27
D · Potential for more than minimal harm
2024-01-27
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 2024-02-16
D · Potential for more than minimal harm
2024-01-27
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-27
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-27
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-27
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 2024-01-29
D · Potential for more than minimal harm
2024-01-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-20
E · Potential for more than minimal harm
2022-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-19
E · Potential for more than minimal harm
2022-11-18
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-11-18
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 2022-12-12
D · Potential for more than minimal harm
2022-11-18
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-11-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-12-15
Penalties and ownership
What sits behind the stars
Ownership
Guadalupe County Hospital Board
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Gann, Kody
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Newsome, Garrett
Operational/Managerial Control · Individual
Riverwalk Healthcare Inc
Operational/Managerial Control · Organization
Yu, Haoran
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Avir at New Braunfels
New Braunfels, TX
1-star overall rating with 1-star inspections with $374,761 in total fines with 24 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Sundance Inn Health Center
New Braunfels, TX
3-star overall rating with 2-star inspections with abuse icon flag with $6,364 in total fines with 15 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Eden Home
New Braunfels, TX
3-star overall rating with 3-star inspections with $22,205 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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