Show Inspection Reports
Total health inspections
7
Texas average 7.4
Last Health inspection on Nov 2024
Primarily short stays
Residents typically stay for brief periods, with frequent admissions and discharges throughout the year.
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Nursing Home in Kyle
CMS overall rating
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Legend Oaks Rehabilitation and Healthcare – Kyle
Nursing Home in Kyle
CMS overall rating
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Legend Oaks Rehabilitation and Healthcare – Kyle
Overview of Legend Oaks Rehabilitation and Healthcare – Kyle
In the heart of Kyle, Texas, sits Legend Oaks Rehabilitation and Healthcare – Kyle, a for-profit nursing home dedicated to providing exceptional care and services. Certified by Medicaid and Medicare, this facility stands equipped to offer both short-term rehabilitation and long-term care services, boasting a capacity of 126 beds inclusive of private and semi-private rooms. It’s not just a facility; it’s a place where residents rediscover their strength and mobility, forging a new home filled with care and support.
At Legend Oaks, a talented and devoted staff collaborates closely with residents, their families, and healthcare providers to craft comprehensive care and treatment plans. The facility’s in-house therapy team blends cutting-edge techniques with hands-on approaches, ensuring a tailored and effective approach to rehabilitation and care. Beyond the exceptional care, Legend Oaks fosters an environment brimming with diverse activities curated to suit individual preferences, promoting an active lifestyle for residents.
Quality ratings
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Nursing care per resident
This shows how many total hours of nursing staff time are available per resident each day. Higher numbers usually mean more staff support.
Staffing hours breakdown
Hours of care per resident per day, broken down by staff type. Data from CMS Medicare.
Registered Nurse (RN)
Registered nurse hours per resident per day.
Registered nurse hours per resident per day.
Nurse Aide
Nurse aide hours per resident per day.
Nurse aide hours per resident per day.
Total Nursing (Weekend)
Total number of nurse staff hours per resident per day on weekends.
Total number of nurse staff hours per resident per day on weekends.
Physical Therapist
Physical therapist staff hours per resident per day.
Physical therapist staff hours per resident per day.
RN (Weekend)
Registered nurse hours per resident per day on weekends.
Registered nurse hours per resident per day on weekends.
Capacity and availability
Medium-capacity home
Offers a balance of services and community atmosphere.
Total beds
126
This home usually has limited availability
Occupancy is moderate, suggesting balanced demand.
Occupancy rate
86.1%
Residents per day (avg)
113
Occupancy rate
86.1%
Residents per day (avg)
113
Who this home usually serves
Show admissions and discharges
TYPE OF STAY
Might be optimal for
Post-acute recovery
Temporary care
Transitional stays
Breakdown by payment type
Medicare
29% of new residents, usually for short-term rehab.
Typical stay
24 days
Private pay
69% of new residents, often for short stays.
Typical stay
1 months
Medicaid
2% of new residents, often for long-term daily care.
Typical stay
5 years
Finances and operations
Governmental community
Operated by state authorities.
Home revenue
$16.1M
Surplus of revenue
$1.2M
Governmental community
Operated by state authorities.
Home revenue
$16.1M
Surplus of revenue
$1.2M
Payroll costs
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
$7.0M
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Other operating costs
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
$7.9M
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
Total costs
$14.8M
126-bed community
A larger shared setting that may offer more common spaces and organized community services.
15 years in operation
A community with a solid operating history and experience delivering ongoing care.
Walk Score: 26 / 100
Somewhat walkable. A few nearby services may be reachable on foot, but most trips require transportation.
Services
About this community
Facility TypeNursing
IssuanceJanuary 4, 2023
ExpirationJanuary 4, 2026
CountyHAYS
License Number147275
Year Opened2/8/2011
Legend Oaks Rehabilitation and Healthcare – Kyle is administrated by Gabriel Barraza.
Management CompanyTREATY HEALTHCARE INC
OwnerGUADALUPE COUNTY HOSPITAL BOARD
Ownership TypeHOSPITAL DISTRICT/AUTHORITY
Medicaid and Medicare
126 units
Total beds
126 units
Staffing
Key information about the people who lead and staff this community.
Administrator Email
[email protected]
Accept Medicaid
Accept Medicare
Rehabilitation Services
Skilled Nursing
Specific ProgramsIn-house Therapy, Skilled Nursing, Stay Active, Activities & Excursions, Church Services
Religious ServicesYes
Types of Care at Legend Oaks Rehabilitation and Healthcare – Kyle
Memory Care
Nursing Home
Access & Eligibility
Ways to qualify for care at this community, including accepted programs and payment options.
Medicaid Accepted
This facility is certified for eligible Medicaid services.
Medicare Accepted
This facility is certified for eligible Medicare services.
Inspection History
In Texas, the Health and Human Services Commission (HHSC) is the primary regulatory body that conducts unannounced inspections and publishes quality reports for all long-term care homes.
9 visits/inspections
4 visits/inspections triggered by complaints
1 routine inspections
Results
6 with issues
3 without issues
Latest inspection
Date
November 20, 2024
Complaint Investigation25 deficiencies
Deficiencies indicate regulatory issues. A higher number implies the facility had several areas requiring improvement.
Texas average: 32 deficiencies
Health Inspection History
Inspections
Total health citations
25
Texas average 25.9
Citations per inspection
3.57
Texas average 3.67
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
15 of 25 citations resulted from standard inspections; and 10 of 25 resulted from complaint investigations.
Breakdown of citation severity (last 3 years)
Critical Health citations
0
0
100% better than Texas averageTexas average: 2
Serious Health citations
0
0
100% better than Texas averageTexas average: 0.4
0 critical citations
0 serious citations
25 moderate citations
0 minor citations
Citations history (last 3 years)
Abuse/Neglect moderate citation
Issues related to protecting resident's from harm, including abuse, neglect, or mistreatment.
Nov 20, 2024
Issues related to protecting resident's from harm, including abuse, neglect, or mistreatment.
Nov 20, 2024
Corrected
Infection Control moderate citation
Issues related to preventing and controlling infections, including hygiene practices and safety protocols.
Nov 20, 2024
Issues related to preventing and controlling infections, including hygiene practices and safety protocols.
Nov 20, 2024
Corrected
Environmental moderate citation
Issues related to building safety, cleanliness, maintenance, and overall living conditions.
Sep 05, 2024
Issues related to building safety, cleanliness, maintenance, and overall living conditions.
Sep 05, 2024
Corrected
Nutrition moderate citation
Issues related to food quality, meal service, and resident's nutritional needs.
Sep 05, 2024
Issues related to food quality, meal service, and resident's nutritional needs.
Sep 05, 2024
Corrected
Data sourced from CMS Health Deficiencies reports. Citation severity codes range from A (least serious) to L (most serious). Immediate Jeopardy (J-L) citations indicate situations where the facility's noncompliance has placed residents at risk of death or serious harm.
Compare Nursing Homes around Kyle The information below is reported by the Texas Health and Human Services Commission.
Filter by care type
Legend Oaks Rehabilitation and Healthcare – Kyle
NH
Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL
Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
Kyle
126
86.1%
+36%
3.42
-6%
0
25
3.6
0
113
-
26
Treaty Healthcare, Inc
$16.1M
$7.0M
43.3%
676272
Places of interest near Legend Oaks Rehabilitation and Healthcare – Kyle
2.7 miles from city center — 2.34 miles to nearest hospital (Ascension Seton Hays)
Calculate Travel Distance to Legend Oaks Rehabilitation and Healthcare – Kyle
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Staffing Data (Q2 2025)
This data corresponds to Q2 2025 and is based on CMS Payroll-Based Journal.
Total staff
170
Employees
167
Contractors
3
Staff to resident ratio
1.59:1
6% better than Texas averageTexas average ratio: 1.51:1
Avg staff/day
62
Average shift
8 hours
0% compared with Texas averageTexas average: 8.1 hours
Total staff hours (quarter)
45,135
Nursing staff breakdown
Registered Nurse
Manages medical care and health needs.
Total count
8
Average shift length
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.4 hours
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.4 hoursNo contractors work on this role.
Licensed Practical Nurse
Assists with medical care and medications.
Total count
23
Average shift length
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.8 hours
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.8 hoursNo contractors work on this role.
Certified Nursing Assistant
Helps with daily care and mobility.
Total count
74
Average shift length
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.6 hours
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.6 hoursNo contractors work on this role.
Contractor staffing
Total hours from contractors
0.5%
228 contractor hours this quarter
Medical Director: 1
Occupational Therapy Assistant: 1
Occupational Therapy Aide: 1
Staff by category
| Certified Nursing Assistant | 74 | 0 | 74 | 17,027 | 91 | 100% | 7.6 |
| Licensed Practical Nurse | 23 | 0 | 23 | 7,952 | 91 | 100% | 9.8 |
| Medication Aide/Technician | 10 | 0 | 10 | 2,912 | 91 | 100% | 9 |
| Physical Therapy Aide | 7 | 0 | 7 | 2,185 | 91 | 100% | 7.4 |
| Respiratory Therapy Technician | 7 | 0 | 7 | 2,074 | 84 | 92% | 6.5 |
| Physical Therapy Assistant | 8 | 0 | 8 | 1,900 | 88 | 97% | 6.5 |
| Speech Language Pathologist | 5 | 0 | 5 | 1,832 | 70 | 77% | 7.2 |
| Registered Nurse | 8 | 0 | 8 | 1,793 | 86 | 95% | 9.4 |
| Qualified Social Worker | 8 | 0 | 8 | 1,755 | 76 | 84% | 7 |
| RN Director of Nursing | 4 | 0 | 4 | 1,682 | 65 | 71% | 9 |
| Clinical Nurse Specialist | 4 | 0 | 4 | 1,258 | 66 | 73% | 8.6 |
| Dental Services Staff | 2 | 0 | 2 | 647 | 64 | 70% | 7 |
| Nurse Practitioner | 2 | 0 | 2 | 594 | 65 | 71% | 9 |
| Administrator | 1 | 0 | 1 | 520 | 65 | 71% | 8 |
| Dietitian | 2 | 0 | 2 | 504 | 63 | 69% | 8 |
| Other Dietary Services Staff | 1 | 0 | 1 | 185 | 31 | 34% | 6 |
| Medical Director | 0 | 1 | 1 | 110 | 10 | 11% | 11 |
| Therapeutic Recreation Specialist | 1 | 0 | 1 | 90 | 15 | 16% | 6 |
| Occupational Therapy Assistant | 0 | 1 | 1 | 88 | 8 | 9% | 11 |
| Occupational Therapy Aide | 0 | 1 | 1 | 31 | 3 | 3% | 10.2 |
74 Certified Nursing Assistant
% of Days
100%
23 Licensed Practical Nurse
% of Days
100%
10 Medication Aide/Technician
% of Days
100%
7 Physical Therapy Aide
% of Days
100%
7 Respiratory Therapy Technician
% of Days
92%
8 Physical Therapy Assistant
% of Days
97%
5 Speech Language Pathologist
% of Days
77%
8 Registered Nurse
% of Days
95%
8 Qualified Social Worker
% of Days
84%
4 RN Director of Nursing
% of Days
71%
4 Clinical Nurse Specialist
% of Days
73%
2 Dental Services Staff
% of Days
70%
2 Nurse Practitioner
% of Days
71%
1 Administrator
% of Days
71%
2 Dietitian
% of Days
69%
1 Other Dietary Services Staff
% of Days
34%
1 Medical Director
% of Days
11%
1 Therapeutic Recreation Specialist
% of Days
16%
1 Occupational Therapy Assistant
% of Days
9%
1 Occupational Therapy Aide
% of Days
3%
Facility Characteristics
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total census
107 residents
Residents by payment source
Medicare
10 residents (9.3%)
Medicaid
57 residents (53.3%)
Private pay or other
40 residents (37.4%)
Programs & Services
Residents' Group
Residents meet regularly to discuss policies, care quality, and activities
Active Resident Council
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
Quality of care over time
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
High-risk clinical events score
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
14.9
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
14.9
73% worse than Texas averageTexas average: 8.6
Functional decline score
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
28.5
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
28.5
77% worse than Texas averageTexas average: 16.0
Long-stay resident measures
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Need for Help with Daily Activities Increased
Percent of long-stay residents whose need for help with daily activities has increased
33.0%
Percent of long-stay residents whose need for help with daily activities has increased
33.0%
104% worse than Texas averageTexas average: 16.2%
Walking Ability Worsened
Percent of long-stay residents whose ability to move independently worsened
35.3%
Percent of long-stay residents whose ability to move independently worsened
35.3%
118% worse than Texas averageTexas average: 16.2%
Low Risk Residents with Bowel/Bladder Incontinence
Percent of low risk long-stay residents who lose control of their bowels or bladder
17.0%
Percent of low risk long-stay residents who lose control of their bowels or bladder
17.0%
9% worse than Texas averageTexas average: 15.7%
Falls with Major Injury
Percent of long-stay residents experiencing one or more falls with major injury
2.1%
Percent of long-stay residents experiencing one or more falls with major injury
2.1%
35% better than Texas averageTexas average: 3.2%
High Risk Residents with Pressure Ulcers
Percent of long-stay high risk residents with pressure ulcers
3.6%
Percent of long-stay high risk residents with pressure ulcers
3.6%
20% better than Texas averageTexas average: 4.4%
Urinary Tract Infection
Percent of long-stay residents with a urinary tract infection
0.9%
Percent of long-stay residents with a urinary tract infection
0.9%
15% worse than Texas averageTexas average: 0.8%
Lost Too Much Weight
Percent of long-stay residents who lose too much weight
0.3%
Percent of long-stay residents who lose too much weight
0.3%
90% better than Texas averageTexas average: 3.5%
Depressive Symptoms
Percent of long-stay residents who have depressive symptoms
1.0%
Percent of long-stay residents who have depressive symptoms
1.0%
65% better than Texas averageTexas average: 2.9%
Antipsychotic Use
Percent of long-stay residents who received an antipsychotic medication
3.1%
Percent of long-stay residents who received an antipsychotic medication
3.1%
61% better than Texas averageTexas average: 7.9%
Pneumococcal Vaccine
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
97.0%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
97.0%
In line with Texas averageTexas average: 97.3%
Influenza Vaccine
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
87.6%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
87.6%
11% worse than Texas averageTexas average: 97.9%
Hospitalizations per 1,000 days
Number of hospitalizations per 1,000 long-stay resident days.
1.67
Number of hospitalizations per 1,000 long-stay resident days.
1.67
22% better than Texas averageTexas average: 2.13
ED visits per 1,000 days
Number of outpatient emergency department visits per 1,000 long-stay resident days.
1.11
Number of outpatient emergency department visits per 1,000 long-stay resident days.
1.11
46% better than Texas averageTexas average: 2.07
Short-stay resident measures
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Pneumococcal Vaccine
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
93.5%
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
93.5%
In line with Texas averageTexas average: 90.4%
Antipsychotic medication increase
Percent of short-stay residents who newly received an antipsychotic medication
0.0%
Percent of short-stay residents who newly received an antipsychotic medication
0.0%
100% better than Texas averageTexas average: 1.4%
Influenza Vaccine
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
94.9%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
94.9%
8% better than Texas averageTexas average: 88.0%
Re-hospitalized after SNF stay
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
18.5%
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
18.5%
29% better than Texas averageTexas average: 25.9%
Emergency department visits
Percentage of short-stay residents who had an outpatient emergency department visit.
9.7%
Percentage of short-stay residents who had an outpatient emergency department visit.
9.7%
19% better than Texas averageTexas average: 12.0%
Falls with major injury
Percentage of SNF residents who experience falls with major injury during their stay.
0.8%
Percentage of SNF residents who experience falls with major injury during their stay.
0.8%
In line with Texas averageTexas average: 0.8%
Ability to care for self at discharge
Percentage of residents at or above expected ability to care for themselves at discharge.
56.6%
Percentage of residents at or above expected ability to care for themselves at discharge.
56.6%
5% better than Texas averageTexas average: 53.7%
Successful return to home or community
Rate of successful return to home or community from a skilled nursing facility.
60.6%
Rate of successful return to home or community from a skilled nursing facility.
60.6%
20% better than Texas averageTexas average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
Financial Trends
Historical financial and operational data for Legend Oaks Rehabilitation and Healthcare – Kyle based on CMS SNF Cost Reports.
Occupancy Rate
86.1%
↑ 10.7pp vs 2022
Net Income
$1.2M
↑ ~$319.1K vs 2022
Total Payroll
$8.0M
↑ ~$827.2K vs 2022
Profit Margin
7.6%
↑ 1.3pp vs 2022
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