The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited December 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
Nursing home report
Legend Oaks Healthcare and Rehabilitation-Kyle
Kyle, TX · Medicare-certified · 126 beds
Needs attention
For-profitChain member
2 of 5 overall
Legend Oaks Healthcare and Rehabilitation-Kyle has an overall rating of 2 out of 5 stars, with especially weak staffing at 1 out of 5 and reported nurse staffing below the federal benchmark (3.21 vs. 4.1 hours per resident per day). It also has a recent federal penalty and $12,735 in fines in the last 24 months; inspection and quality measures are both 3 out of 5 stars.
Facility ratings
Health inspections
Staffing
3.2148 hrs/resident/day
Quality measures
Last inspection: January 29, 2026Penalties, last 24 months: $12,735recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.2148.
Staffing detail
- Registered nurses
- 0.36
- Licensed practical nurses
- 0.92
- Nurse aides
- 1.94
- Weekend nursing
- 2.63
Hours per resident per day.
Total staff turnover: 43%
Registered nurse turnover: 60%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
1.6%5.1%Worsening
Residents with a fall causing major injury
1.2%3.4%Worsening
Residents with pressure ulcers (bedsores)
4.9%2.1%Improving
Residents with a urinary tract infection
0%2.4%Worsening
Residents who lost too much weight
0%0%No change
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
30.7%15.4%Improving
Residents whose ability to walk got worse
—36.3%—
Long-stay residents on antianxiety or sleep medication
12.3%13.3%Worsening
Short-stay residents newly given an antipsychotic
0%0.7%Worsening
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
17.6%11.7%Improving
Residents with depressive symptoms
1.3%1.2%No change
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—87.6%—
Long-stay residents given the pneumonia vaccine
95.3%98.9%Improving
Short-stay residents given the seasonal flu vaccine
—94.9%—
Short-stay residents given the pneumonia vaccine
94.8%90.4%Worsening
What the inspectors found
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited December 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The home failed to ensure residents had a safe, clean, comfortable, homelike environment and daily care supports were provided safely. Cited January 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 584 — 42 CFR §483.10 — S/S: E
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited November 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: E
The home failed to ensure residents were treated with dignity and could make their own choices and communicate freely. Cited September 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 550 — 42 CFR §483.10(a) — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- PENALTY
A federal fine of $12,735 was recorded.
- INSPECTION
Health inspection found 4 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $12,735 in total fines.
- $12,735
Federal fine
Dec 12, 2025
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of THE ENSIGN GROUP · 338 homes · 3.2 stars avg
- Occupancy
- 116.1 residents on an average day (92% of 126 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 15 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.