Legend Oaks Healthcare And Rehabilitation-kyle
Legend Oaks Healthcare and Rehabilitation-Kyle in Kyle, TX — inspection on May 26, 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.
Inspection Findings
Observation of the humidifier bottle revealed the date written on it was 05/17/26.
Record review of the MAR of Resident #3 revealed LPN A documented that the Oxygen tubing &humidifier bottle were changed on 05/24/26.During a telephone interview on 05/26/26 at 1:35 pm, LPN A stated that he served as the night shift nurse for Hall 100 on 05/18/26. He indicated that it was his responsibility as the Sunday night shift nurse to change the humidifier bottles and oxygen tubes for residents in that hall. He identified Residents #1, Resident#2, and Resident#3 as being on continuous oxygen therapy provided by an oxygen concentrator. LPN A said that he had planned to change these items but, due to being occupied with other nursing tasks, he forgot to do so. He said that regular changing of these components was necessary to minimize the risk of respiratory infections and stated that failing to do so compromised infection control protocols. He said that it was the duty of every nurse to adhere to physician's orders by administering medications, therapies, and treatments as prescribed. He stated that he was aware that nurses are supposed to sign the MAR only after completing the task. He said that he marked the task as completed in advance in MAR, before actually performing it, and stated that this practice was not compliant with professional standards. He said he would not repeat this mistake in the future.
During an interview on 05/26/26 at 1:45pm, LVN B stated that she was the charge nurse on Hall 100 on 05/24/26.
She reported that approximately 30 minutes prior, the ADON had asked her to check whether the humidifiers of Residents #1,Resident #2, and Resident#3 had been changed on 05/24/26, and to change them if they had not.
She stated that she had replaced the humidifier bottles and oxygen tubes for all three residents, as they had not been changed on the specified date. LVN B explained that the physician's order specifically required these components to be changed every Sunday during the night shift.
She noted that although she routinely checked the equipment daily, she did not notice in the last two days that the changes had not been completed.
She stated that routine replacement was important to reduce the risk of infection.
She stated that she had not noticed that the task had been marked as completed on 05/24/26 , on the MAR. LVN B explained that part of her responsibilities included the administration of medication and treatments, and she would only document in the MAR after administering each medication or treatment, not beforehand.In an interview conducted on 05/26/26 at 3:00 pm, the DON stated that humidifier bottles, tubing, and oxygen nasal cannulas should be removed and replaced with new ones as ordered by the physician.
She explained that this practice was intended to minimize the risk of respiratory infections caused by contaminated equipment.
The DON further clarified that it was the responsibility of the nurse on the Sunday night shift to ensure that this task was completed routinely.
She also stated that all nurses on other shifts had a duty to verify that the Sunday night nurse had completed this task and to make replacements as soon as they were noticed if not.
She stated that nurses are supposed to document a task in the medical record only after it has been completed.
She said that false documentation could negatively impact the residents' plan of care and that in turn negatively impact the quality of care.
Record review of the in-service since Marh 2026 revealed there were no in services on safe handling of respiratory equipment.Review of the facility policy Oxygen Administration(Mask, Cannula, Catheter)revised in May,2007 reflected : It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained.2.
Oxygen tubbing is to be replaced every seven (7) days.
Oxygen masks or nasal prongs are to be replaced every seven (7) days.3.
Replace disposable humidifiers every seven (7) days or as needed when empty.
676272 05/26/2026
Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640
Observation of the humidifying
05/24/26.During a telephone interview on 05/26/26 at 1:35pm, LPN A stated that he served as the
night shift nurse to change the humidifier bottles and oxygen tubes for residents in that hall. He identified Residents #1, Resident#2, and Resident#3 as being on continuous oxygen therapy provided by an oxygen concentrator. LPN A said that he had planned to change these items but, due to being occupied with other nursing tasks, he forgot to do so. He stated that he was aware that nurses are supposed to sign the MAR only after completing the task. He said that he marked the task as completed in advance in MAR, before actually performing it, and stated that this practice was not compliant with professional standards. He said he would not repeat this mistake in the future.During an interview on 05/26/26 at 1:45pm, LVN B stated that she was the charge nurse on Hall 100 on that day.
She reported that approximately 30 minutes prior, the ADON had asked her to check whether the humidifiers of Residents #1,Resident #2, and Resident#3 had been changed on 05/24/26, and to change them if they had not.
She confirmed that she had replaced the humidifier bottles and oxygen tubes for all three residents, as they had not been changed on the specified date. LVN B explained that the physician's order specifically required these components to be changed every Sunday during the night shift.
She stated that she had not noticed that the task had been marked as completed on 05/24/26 , on the MAR. LVN B explained that part of her responsibilities included the administration of medication and treatments, and she would only document in the MAR after administering each medication or treatment, not beforehand.In an interview conducted on 05/26/26 at 3:00 pm, the DON stated that humidifier bottles, tubing, and oxygen nasal cannulas should be removed and replaced with new ones as ordered by the physician.
She explained that this practice was intended to minimize the risk of respiratory infections caused by contaminated equipment.
The DON further clarified that it was the responsibility of the nurse on the Sunday night shift to ensure that this task was completed routinely.
She stated that nurses are supposed to document a task in the medical record only after it has been completed.
She said that false documentation could negatively impact the residents' plan of care and that in turn negatively impact the quality of care.
Record review of the facility policy Documentation and Charting revised in July 2022 indicated POLICY:It is the policy of this facility to provide.1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.