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Complaint Investigation

Legend Oaks Healthcare And Rehabilitation-kyle

January 29, 2026 · Kyle, TX · 1640 Fairway
Citations 2
CMS Rating 2/5
Beds 126
Provider ID 676272
Healthcare Facility
Legend Oaks Healthcare And Rehabilitation-kyle
Kyle, TX  ·  View full profile →
Inspection Summary

Legend Oaks Healthcare and Rehabilitation-Kyle in Kyle, TX — inspection on January 29, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0552
Resident Rights Deficiencies
Potential for More Than Minimal Harm

During an exit conference interview on 01/29/2026 at 3:45 PM, DON B stated that Resident #1 was notified by the nurse practitioner that Tamiflu was being started.

The DON stated that the nurse practitioner did not notify all residents, only some.

The DON stated that Resident #1 had a BIMs of 12 and that his RP/FM was notified to start the medication.

The DON stated that residents did not have to have a MPOA in place to notify the FM.

Review of the facility policy titled ‘Resident Rights and Responsibilities, Notice of with revision date of 04/2025 reflected should a resident be found incompetent by a court of law, the resident's representative shall act on behalf of the resident.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation-Kyle

1640 Fairway Kyle, TX 78640

SUMMARY STATEMENT OF DEFICIENCIES

Review of work order log reflected request for Resident #1's curtain to be changed with note privacy curtain has BM on it with an open date of 01/08/2026 and close date of 01/15/2026.

Review of work order log reflected request for Resident #1's curtain needed to be cleaned with an open date of 01/10/2026 and close date of 01/12/2026 with a note of repeat.

Review of work order log reflected request for Resident #1's room with note privacy curtain needs to be washed with an open date of 1/14/2026 and close date of 1/15/2026.

Review of work order log reflected request for Resident #1's curtain to be changed with note curtain has poop on it please change it with an open date of 01/27/2026 and close date of 01/29/2026.

Review of facility policy titled Physical Environment with revision date of 05/2023 reflected the facility utilized TELS to track and document maintenance and regular tasks.

Review reflected that it was the policy of the facility to establish procedures to ensure the facility remains in good working order for resident and staff safety.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Kyle, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Legend Oaks Healthcare and Rehabilitation-Kyle or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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