Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legend Oaks Healthcare And Rehabilitation-kyle during CMS and state inspections, most recent first.
Surveyors found that multiple residents had stained privacy curtains that were not promptly cleaned or replaced, despite repeated work orders documenting large dark or feces-like stains and bowel movement on the curtains. One resident with post-stroke hemiplegia and moderate cognitive impairment reported that a CNA splattered bowel movement on his curtain, attempted to wipe it off, and that the stain remained for weeks, affecting family visits. Other residents with conditions including paroxysmal AFib, muscle weakness, post-polio syndrome, and major depressive disorder reported brown splatters and streaks on their curtains and believed they were rarely laundered. Staff interviews showed reliance on a TELS work-order system, uncertainty among nursing staff about laundering frequency, and a practice of monthly deep-cleaning rotations, resulting in stained curtains remaining in resident rooms for extended periods.
A resident with a history of stroke and moderate cognitive impairment, but described by staff as able to consent and oriented, was started on oseltamivir (Tamiflu) prophylaxis after exposure to influenza A. The resident’s POA documents granted only financial authority to family members, with no medical decision-making authority, yet staff documented notifying the responsible party and obtaining approval for the medication without documenting any discussion with the resident. The resident reported he was not told about the new flu medication or its purpose until several days later, learning of it from family rather than staff, and stated he was capable of making his own decisions and wanted to be consulted. Multiple staff, including an LPN, RN, ADON, DONs, and the administrator, acknowledged that residents should be informed of new medications and that this should be documented, but there was no record that this resident was informed prior to initiation of the antiviral therapy.
A medical assistant in an LTC facility failed to sanitize a blood pressure monitor between uses on two residents, both with severe cognitive impairments and multiple health conditions. Additionally, personal drinks were observed on the medication cart, contrary to facility policy. The facility's infection control program requires equipment disinfection to prevent infection spread.
A resident with severe cognitive impairment was physically and emotionally abused by another resident with moderate cognitive impairment and behavioral issues. The incident occurred when the aggressive resident grabbed the other's arm, causing redness, as she attempted to enter a room. Despite staff training on abuse and neglect, the facility failed to prevent this altercation.
Two residents in an LTC facility were observed wearing dirty clothing throughout the day, compromising their dignity. Despite requiring assistance with personal care, staff failed to change their soiled clothes after meals, as per facility policy. Interviews with staff revealed a lack of adherence to the expected practice of maintaining residents' dignity by ensuring clean clothing.
The facility failed to ensure resident privacy by not knocking before entering rooms. Staff members entered the rooms of four residents without knocking, violating their right to privacy. Despite being aware of the policy, staff cited reasons such as rushing or habit for not adhering to it. Residents expressed mixed feelings, with some desiring consistent knocking. The facility's policy emphasizes residents' rights to dignity and privacy.
The facility failed to maintain professional standards for food service safety due to inadequate hand hygiene by Cook C during food preparation. Despite training, Cook C did not wash hands between tasks, potentially risking cross-contamination. Interviews confirmed staff awareness of hand hygiene protocols, but these were not followed, as observed during the preparation of pureed foods.
A resident's OOH-DNR form was found incomplete, missing required signatures from the resident, witnesses, and physician, leading to a deficiency in honoring the resident's rights to request, refuse, and/or discontinue treatment. Despite the resident's care plan indicating a DNR status, the form's invalidity was confirmed by staff, highlighting a failure in the facility's process for verifying advanced directives.
A resident with dementia and other health issues did not receive necessary nail care, resulting in long, jagged, and dirty fingernails. Despite requiring moderate to extensive assistance with personal hygiene, there was no documentation of nail care for nearly a month. Interviews with staff revealed a lack of clarity and responsibility regarding nail care, placing the resident at risk of skin tears and infection.
The facility failed to assist two residents in obtaining necessary dental services, despite their requests and visible dental issues. Both residents, who were cognitively intact, had not seen a dentist in the past year. Staff interviews revealed a lack of communication and follow-up regarding their dental needs, and the facility did not adhere to its policy requiring prompt referral for dental services.
A resident's call light system was found to be non-functional, preventing them from alerting staff for assistance. The resident, who was at risk for falls, expressed concerns about staff response times. Staff confirmed the malfunction, and faulty wiring was identified and replaced. The facility's policy required immediate reporting of defective call lights.
Soiled Privacy Curtains Not Timely Cleaned or Replaced
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not ensuring that privacy curtains for three residents were free of stains. For Resident #1, a male with a history of cerebral infarction and resulting hemiplegia/hemiparesis and moderate cognitive impairment (BIMS 12), surveyors observed housekeeping staff on a ladder replacing the middle privacy curtain in his room. Resident #1 reported that the curtain had been dirty for approximately two to three weeks, stating that a CNA had splattered bowel movement on the curtain while changing his roommate, attempted to wipe it off, but the stain remained and no one made an effort to clean it afterward. He also reported that a similar incident had occurred previously, that his family member had reported it, and that his family did not want to sit near the curtain during visits. For Resident #2, a female with paroxysmal atrial fibrillation, muscle weakness, and a cognitive communication deficit but no cognitive impairment (BIMS 14), observation revealed several brown splattered dots on the privacy curtain between her and her roommate. Resident #2 stated she did not know what was on the curtain, wished it could be washed, and was unsure if the curtain had ever been washed since she had been in the room. For Resident #3, a male with post-polio syndrome, major depressive disorder, and a need for assistance with personal care, and no cognitive impairment (BIMS 15), observation showed brown streaks and spots on the middle privacy curtain in his room. Resident #3 stated he did not think the curtain was laundered very often and believed the stains were food. Staff interviews revealed inconsistent understanding and implementation of procedures for handling soiled privacy curtains. CNAs and nursing staff reported that when curtains were soiled, they were to submit a work order in the TELS system and notify maintenance or housekeeping, and that nursing staff could not remove curtains themselves. Some staff, including an LVN and an RN, were unsure about the routine frequency for laundering curtains. The housekeeping supervisor and maintenance staff stated that privacy curtains were laundered on a monthly deep-cleaning rotation and as needed via TELS work orders, with increased urgency if bodily fluids or bowel movement were noted. Review of TELS work order logs showed multiple requests over several weeks for curtains in Resident #1’s room and another room to be changed or washed due to large dark or feces-like stains, including repeated notes that the curtain had a large stain that looked like feces for well over two weeks, and specific entries indicating the curtain had bowel movement or “poop” on it. The facility’s physical environment policy stated that TELS was used to track and document maintenance and regular tasks to keep the facility in good working order for resident and staff safety.
Failure to Inform Cognitively Capable Resident of New Antiviral Prophylaxis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively capable resident was informed of and allowed to participate in decisions regarding a new medication order. The resident was an older male with a history of cerebral infarction and resulting hemiplegia/hemiparesis, with a quarterly MDS BIMS score of 12 indicating moderate cognitive impairment. His face sheet and POA documents identified two family members as financial POA only, with no medical decision-making authority or MPOA designation. The resident’s care plan noted risk for impaired cognitive function, but staff interviews consistently described him as able to consent to his own treatment, oriented, and able to recognize people and express his needs. Record review showed that on a January date, the resident was exposed to influenza A in the facility and, per protocol, was started on oseltamivir (Tamiflu) 75 mg orally once daily for influenza A prophylaxis for 14 days, ordered by the in-house provider. A nursing progress note documented that the responsible party was notified and approved the medication, but there was no documentation from the NP, ADON, LVN, or any other staff that the resident himself was informed of the new medication or its purpose between the start of therapy and the survey date. The resident’s immunization record showed he had already received an influenza vaccine earlier in the season, and there was no indication in the chart that he had been found incompetent by a court of law, as referenced in the facility’s resident rights policy. During interviews, the resident stated he was started on “flu medication” and did not learn what it was for until about three days later, after a family member asked if he knew he had been started on Tamiflu and told him the facility had contacted another family member for permission. He stated that he was not “crazy,” could still make his own decisions, and wanted the facility to contact family only if he was unable to decide for himself. He reported that no one came to ask him about starting the medication or whether he wanted to take it. Multiple staff members, including an LVN, RN, ADON, DONs, and the administrator, described that residents should be notified of new medications and that this should be documented, and several acknowledged that this was important for resident autonomy and involvement in care. However, the LVN could not recall if this resident was notified, the ADON stated the nurse or NP was responsible for speaking with residents, and the DON later asserted that the NP had notified this resident, despite the absence of documentation and the resident’s statement that he had not been informed in advance.
Infection Control Breach with Blood Pressure Monitor
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medical assistant (MA A) who did not clean and disinfect a blood pressure monitor between uses on two residents. On the specified date, MA A used the same blood pressure monitor on two residents without sanitizing it before, between, or after the measurements. This oversight occurred despite the facility's policy requiring the cleaning and disinfection of equipment to prevent the spread of infections. Additionally, MA A was observed with personal drinks on the medication cart, which is against the facility's policy. The residents involved were both elderly males with multiple diagnoses, including Type 2 diabetes, hypertension, and dementia, and both had severely impaired cognition as indicated by their BIMS scores. The facility's policy on infection prevention and control, revised in December 2023, outlines the importance of cleaning and disinfection procedures for environmental surfaces and equipment. Despite receiving in-service training on infection control, MA A admitted to not following the policy and was unaware of the reasons behind the prohibition of personal food and drinks on the medication cart.
Resident Abuse Incident Due to Inadequate Protection
Penalty
Summary
The facility failed to protect a resident from physical and emotional abuse by another resident. On the date of the incident, Resident #2 screamed at and grabbed the right arm of Resident #1, who had a history of a nondisplaced fracture of the triquetrum bone in the wrist. This altercation resulted in erythema on Resident #1's arm that lasted for four days. The incident was confirmed through a facility investigation and video footage, which showed Resident #2 coming out of her room and grabbing Resident #1's arm as she attempted to enter the room. Resident #1, a female with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and a history of fractures, was known to ambulate via wheelchair and enjoyed looking out the windows in Hall 100. Despite her cognitive deficits, she was described as pleasant and had no behavioral concerns. Resident #2, who had moderate cognitive impairment and a history of behavioral issues, expressed paranoia about intruders due to past trauma and was on antidepressant medication. The facility had attempted to refer Resident #2 to behavioral health services, but the referral was declined by her and her family. The incident was witnessed by staff, including an LVN and MD, who observed Resident #2's aggressive behavior towards Resident #1. The facility's investigation revealed that contrary to initial impressions, Resident #1 had not entered Resident #2's room but was attempting to open the door when the altercation occurred. The facility had conducted in-services on abuse and neglect, as well as on responding to resident altercations, but the measures in place were insufficient to prevent the incident from occurring.
Failure to Maintain Resident Dignity Through Clean Clothing
Penalty
Summary
The facility failed to ensure the dignity of two residents by not maintaining their clothing in a clean state throughout the day. Resident #34, a female with dementia and other conditions requiring extensive assistance with personal care, was observed wearing a dirty t-shirt with yellow stains throughout the day on 09/04/24. Despite being dependent on staff for dressing and personal hygiene, her clothing was not changed after it became soiled, as documented in the care plan and observed by surveyors. Similarly, Resident #67, a male with Parkinson's disease and dementia, was observed on multiple occasions wearing a dirty shirt and clothing protector with food and moisture stains on 09/03/24 and 09/04/24. His family had previously reported the issue to the facility, but it persisted. The resident required substantial assistance with dressing, yet staff failed to change his clothing after meals, as expected by the facility's policy and care plan. Interviews with staff, including CNAs and nursing management, revealed a lack of adherence to the facility's policy of changing residents' clothing after meals if they became dirty. Staff members acknowledged the expectation to change soiled clothing but failed to notice or act upon the residents' needs. The facility's policy on resident rights emphasizes the importance of maintaining dignity, which was compromised by the failure to provide clean clothing, potentially leading to embarrassment for the residents.
Failure to Ensure Resident Privacy by Not Knocking Before Entering Rooms
Penalty
Summary
The facility failed to ensure resident rights for personal privacy for four residents reviewed for personal privacy. Staff members did not knock on the doors of these residents before entering their rooms, which is a violation of the residents' right to privacy. This practice was observed during meal tray passes, where staff entered the rooms of the residents without knocking, potentially causing the residents to feel that their privacy was being invaded. The residents involved in this deficiency included individuals with various medical conditions such as diabetes, heart failure, dementia, and mobility issues. Despite their medical conditions, these residents had varying levels of cognitive ability, with some being able to understand and communicate effectively. Interviews with the residents revealed mixed feelings about the lack of knocking, with some expressing a desire for staff to knock consistently before entering their rooms. Interviews with staff members, including a CNA, an LVN, the DON, and the ADM, revealed that they were aware of the policy requiring staff to knock before entering residents' rooms. However, reasons for not adhering to this policy included being in a rush, habit, or distraction. The facility's policy on resident rights, dated October 4, 2016, clearly states that residents have the right to be treated with dignity and respect, including the right to personal privacy.
Failure in Hand Hygiene During Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the area of hand hygiene, during food preparation in the kitchen. Cook C was observed on multiple occasions not washing her hands between tasks while preparing pureed foods. This included touching various surfaces and equipment, such as the puree machine blade, stove, and steam table, without performing hand hygiene in between these actions. The lack of proper hand hygiene was noted during the preparation of both meat and green peas, which were then served to residents. Interviews with the Dietary Manager (DM), Cook D, and the Administrator (ADM) confirmed that all kitchen staff had been trained on hand hygiene practices, which require washing hands between tasks to prevent cross-contamination and the spread of infections. Despite this training, Cook C did not follow the hand hygiene protocol, potentially placing residents at risk of food-borne illness. The facility's hand hygiene policy, dated October 2022, mandates that all personnel follow handwashing procedures to prevent the spread of infections, yet this was not adhered to during the observed food preparation process.
Incomplete DNR Form Leads to Deficiency in Resident Rights
Penalty
Summary
The facility failed to ensure the proper completion of an out-of-hospital do-not-resuscitate (OOH-DNR) form for a resident, identified as Resident #49, which is a violation of the resident's rights to request, refuse, and/or discontinue treatment. The OOH-DNR form for Resident #49 was missing required signatures from the resident or proxy, witnesses, and the physician, rendering it invalid. This oversight was discovered during a review of the resident's clinical records and interviews with facility staff. Resident #49 was admitted with multiple diagnoses, including an unspecified fracture of the right femur, sequelae of cerebral infarction, unspecified atrial fibrillation, and dysphagia. The resident's care plan indicated a DNR code status, and physician orders confirmed a DNR order. However, the OOH-DNR form dated 06/06/2019 lacked the necessary signatures, which was confirmed by multiple staff members during interviews. The staff, including LVNs, social workers, and the administrator, acknowledged the form's invalidity due to missing signatures and recognized the potential risk of not honoring the resident's wishes. Interviews with staff revealed that the facility's process for verifying advanced directives was not followed. The LVNs and social workers stated that they are responsible for ensuring that DNR forms are complete and valid before being entered into the resident's record. Despite this, the form for Resident #49 was not properly reviewed, leading to the deficiency. The facility's policy requires that advanced directives be reviewed to ensure they reflect the resident's choices and are signed and dated by the appropriate parties, which was not adhered to in this case.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living, received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not ensure that the resident's fingernails were clean and smooth over a period of several days. The resident, an elderly female with a history of dementia, lack of coordination, and other health issues, required moderate to extensive assistance with personal hygiene. Despite this need, there was no documentation of nail care being provided to her for nearly a month. Interviews with facility staff revealed a lack of clarity and responsibility regarding nail care. A CNA mentioned that the resident's nails often got dirty due to her behavior, but there was no specific assignment for nail care. An LVN and the ADON both acknowledged that nail care should be part of regular hygiene routines, but there was no consistent monitoring or reporting of issues. The DON and ADM also confirmed that nail care was expected to be monitored by nursing staff, yet there was no evidence of this being effectively carried out. This oversight placed the resident at risk of skin tears and infection due to long, jagged, and dirty fingernails.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to assist two residents, Resident #46 and Resident #74, in obtaining necessary dental services. Resident #46, who was cognitively intact with a BIMS score of 13, had been experiencing discomfort with her dentures, which was noted in her care plan. Despite her requests to see a dentist and visible buildup on her teeth, there was no record of her having seen a dentist in the past year. Interviews with staff revealed a lack of communication and follow-up regarding her dental needs, with the social worker and administration unsure of why she had not been referred to a dentist. Resident #74, also cognitively intact with a BIMS score of 15, had no teeth or dentures in her mouth during observation. She reported that her dentures had been broken by a CNA months ago, yet there was no documentation of her being offered dental services. Staff interviews indicated that she often requested softer foods and preferred not to wear her dentures, but there was no record of her being referred to a dentist. The facility's policy requires prompt referral for dental services, but this was not adhered to in her case. The facility's policy on dental services states that residents should have access to routine and emergency dental care without barriers, and that the facility should investigate and determine financial responsibility for denture repairs. However, both residents had not been seen by a dentist in the past year, and there was no documentation of efforts to address their dental concerns. The facility's failure to follow its own policy and ensure timely dental care for these residents constitutes a deficiency in care.
Deficiency in Resident Call Light Functionality
Penalty
Summary
The facility failed to ensure that a working call system was available in each resident's bathroom and bathing area, specifically for one resident. The call button in the bedroom of a resident was not functioning properly, as observed during an inspection. The resident, who was at risk for falls and dependent on staff for assistance, was unable to alert staff for help when needed. The resident expressed concerns about the timeliness of staff response when the call light was pressed. Interviews with staff confirmed the malfunction of the call light system. A CNA verified that the call light was not working at the time of observation, although it had been functioning earlier. The maintenance director identified faulty wiring as the cause and replaced it upon discovery. The DON and the Administrator both acknowledged the importance of having a functioning call light system to meet residents' needs promptly. Maintenance logs showed previous tests indicating the call light was functioning, and the facility's policy required immediate reporting of defective call lights.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kyle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marbridge Villa | 8.3 mi | — | 0 | 0 |
| Brodie Ranch Nursing And Rehabilitation Center | 9.3 mi | — | 3 | 1 |
| Onion Creek Nursing And Rehabilitation Center | 9.7 mi | — | 2 | 0 |
| San Marcos Rehabilitation And Healthcare Center | 10.1 mi | — | 1 | 0 |
| Southpark Meadows Nursing And Rehabilitation Cente | 11.2 mi | — | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.