Legend Oaks Healthcare and Rehabilitation-Kyle

In the surveyor’s words

From the most serious findings on record at Legend Oaks Healthcare and Rehabilitation-Kyle, in the surveyor’s own words.

• Actual harm, isolatedF686Dec 12, 2025

  Based on interview, observation, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #90) of five residents reviewed for pressure injuries. The facility failed to ensure Resident #90 received wound care treatments for eight days after admission, from 11/26/2025 to 12/04/2025. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain.Findings included: Record review of Resident #90's undated face sheet reflected a [AGE] year-old female admitted on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Dec 12, 2025

  Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. 1. The deep fryer was dirty on 12/09/2025.2. The commercial dishwasher did not meet the minimum required threshold for chemical sanitizing on 12/09/2025. This failure could place residents at risk of food-borne illnesses.Findings included: 1. Observation on 12/09/2025 at 9:03 a.m. revealed the deep fryer in the facility kitchen was covered in cornmeal breading crumbs. There were crumbs on the rim of the fryer as well as floating in the oil inside the fryer. […]

• No harm, potential for more than minimal, patternF695May 26, 2026

  Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 5 residents (Resident#1, Resident #2 and Resident#3) reviewed for respiratory care.The facility failed to ensure the humidifier water bottle and oxygen cannula connected to the oxygen concentrator of Resident#1, Resident #2 and Resident #3 were changed every Sunday as ordered by the physician.This failure could place residents at risk for respiratory infections through contamination.Findings included:Resident #1Record review of Resident #1's face sheet dated 05/26/26 reflected Resident #1 was… […]

• No harm, potential for more than minimal, patternF842May 26, 2026

  Based on observation, interview, and record review, the facility failed to ensure that the medical records were in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, readily accessible; and systematically organized for 3 of 5 residents (Resident#1,Resident #2 and Resident#3) reviewed for respiratory care. The facility failed to ensure LPN A not documenting the of changing of water bottle and oxygen cannula connected to the oxygen concentrator of Resident#1, Resident #2 and Resident #3 as completed on 05/24/26, on MARs, when it was not completed on that day, as ordered by the physician.This failure placed residents at risk for respiratory infections through… […]

• No harm, potential for more than minimal, patternF584Jan 29, 2026

  Based on observation, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 4 residents (Resident #1, Resident #2, and Resident #3) reviewed for homelike environment. The facility failed to ensure Resident #1's, Resident #2's and Resident #3's privacy curtains were free of stains. This failure could place residents at risk of living in an unclean or unsanitary environment, decreased quality of life, or shame. […]