Legend Oaks Healthcare And Rehabilitationkyle

Penalties

• Dec 12, 2025 — Fine ($8,407)

Inspection findings

1. May 26, 2026 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Jun 30, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0842 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.

     Corrected Jun 30, 2026 · CMS health inspection

2. Jan 29, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0552 Resident Rights Deficiencies

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

     Corrected Feb 19, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0584 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.

     Corrected Feb 19, 2026 · CMS health inspection

3. Dec 12, 2025 Health · 5 findings
   • Not serious Scope/severity D

     F0636 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.

     Corrected Dec 18, 2025 · CMS health inspection

   • Serious Scope/severity G

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Dec 18, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Dec 15, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 15, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Dec 17, 2025 · CMS fire safety

4. Nov 20, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0600 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.

     Corrected Nov 21, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Nov 21, 2024 · CMS health inspection

5. Sep 5, 2024 Health · 9 findings
   • Not serious Scope/severity E

     F0550 Resident Rights Deficiencies

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

     Corrected Sep 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0578 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.

     Corrected Sep 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Sep 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

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

     Corrected Sep 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0791 Quality of Life and Care Deficiencies

     Provide or obtain dental services for each resident.

     Corrected Oct 7, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Sep 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0919 Environmental Deficiencies

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

     Corrected Sep 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Feb 14, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 10, 2025 · CMS fire safety

6. Nov 21, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Jan 26, 2024 · CMS health inspection

7. Aug 10, 2023 Health · 3 findings
   • Not serious Scope/severity E Complaint

     F0552 Resident Rights Deficiencies

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

     Corrected Aug 22, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0658 Resident Assessment and Care Planning Deficiencies

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

     Corrected Aug 22, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0758 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.

     Corrected Aug 22, 2023 · CMS health inspection

8. Jun 30, 2023 Health · 10 findings
   • Not serious Scope/severity D

     F0578 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.

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

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

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

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

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0758 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.

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0805 Nutrition and Dietary Deficiencies

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

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected Jun 29, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jun 29, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 04/01/2017
• FOWERS, MATTHEW — managing control - governing body, NOT APPLICABLE, since 03/12/2019
• FOWERS, MATTHEW — adp of the snf, NOT APPLICABLE, since 03/12/2019
• FOWERS, MATTHEW — operational/managerial control, NOT APPLICABLE, since 03/12/2019
• GANN, KODY — corporate officer, NOT APPLICABLE, since 02/01/2021
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• KROL, MICHAEL — adp of the snf, NOT APPLICABLE, since 05/01/2016
• KROL, MICHAEL — operational/managerial control, NOT APPLICABLE, since 05/01/2016
• KROL, MICHAEL — managing control - governing body, NOT APPLICABLE, since 05/01/2016
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 05/01/2016
• GUADALUPE COUNTY HOSPITAL BOARD — 5% or greater direct ownership interest, 100%, since 04/01/2017
• NATIONAL HEALTH INVESTORS, INC. — adp of the snf, NOT APPLICABLE, since 04/01/2017
• TEXAS NHI INVESTORS, LLC — adp of the snf, NOT APPLICABLE, since 04/01/2017
• TREATY HEALTHCARE, INC — adp of the snf, NOT APPLICABLE, since 10/07/2025
• TREATY HEALTHCARE, INC — operational/managerial control, NOT APPLICABLE, since 04/01/2017