Legend Oaks Healthcare and Rehabilitationkyle
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 122 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low staffing rating (2/5 stars)
- High RN turnover (54%)
Top 25% in Texas · Critically understaffed (RN) · Chain outperformer · $12,735 in fines
What this means for your family
This facility is an excellent choice for physical and occupational therapy, with many families reporting significant recovery progress. However, you must be vigilant regarding daily care; specifically, monitor for timely medication administration and ensure that hygiene needs and call lights are being addressed promptly by the nursing staff.
Google Reviews
Google Reviews
122 reviews on Google“Legend Oaks offers a highly regarded rehabilitation program with a therapy team that many families find exceptional for recovery. While many reviewers praise the compassionate social workers and friendly front-desk staff, there are serious, recurring reports of neglect regarding hygiene, delayed medication administration, and slow response times to call lights.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate and professional therapy team
- Friendly and welcoming administrative staff
- Clean and well-maintained facilities
- Effective social work and admissions support
Concerns
- Delayed response to call lights and hygiene needs (mentioned by 6 reviewers)
- Medication administration delays or errors (mentioned by 4 reviewers)
- Inconsistent food quality and temperature (mentioned by 3 reviewers)
- Staffing shortages and distracted employees (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 123 analyzed
How They Respond to Reviews
The owner provides personalized responses that frequently reference specific details from the reviews, such as staff names or family members. They maintain a professional and appreciative tone across both positive and negative feedback.
Questions for Your Tour
- 1I've heard wonderful things about your therapy team and administrative staff; how do they work together to support a new resident's transition into the community?
- 2What specific steps are in place to ensure call lights are answered promptly and hygiene needs are met throughout the day?
- 3How does the nursing team manage medication schedules to ensure everything is administered accurately and on time?
- 4Can you tell me more about the dining experience, specifically how you ensure meals are served at the right temperature and maintain consistent quality?
- 5What is the protocol for handling medical emergencies or changes in health status during the overnight hours?
- 6What kind of social activities or daily programs are available to keep residents engaged and connected with one another?
Personalized based on this facility's data
Key Review Excerpts
“The nurses are attentive and compassionate, and the therapists are patient, encouraging, and genuinely invested in progress and dignity.”
“My mother was a pancreatic, cancer, hospice patient at this place for 3 months. It was nothing short of complete chaos the entire time she was there. Her cancer narcotics would not be administered on time (over 3 hours late) or given at all.”
“I had an outstanding experience with Sabina De Jesus and Amy Saenz, who both provided exceptional customer service as I navigated the complex process of arranging skilled nursing and at-home care for my mother.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
11
measures
3
measures
3
measures
Residents whose walking got worse
Residents on antipsychotic medication
Residents needing more daily help over time
Residents vaccinated for the flu
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on anti-anxiety or sleep medication
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility has concerning deficiency patterns with families filing multiple complaints that triggered inspections across several years. The most recurring issues involve resident rights violations (including dignity and informed consent), nutrition and dietary problems, and medication management failures. While most past deficiencies show corrections, recent complaints in 2024-2026 indicate ongoing problems with resident protection, facility safety standards, and infection control, suggesting persistent care quality challenges that families should carefully evaluate before placement.
Jan 29, 2026Complaint2
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Dec 12, 2025Routine5
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Smoke Deficiencies
Provide properly protected cooking facilities.
Nov 20, 2024Complaint2
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Sep 5, 2024Routine9
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Nov 21, 2023Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Aug 10, 2023Complaint3
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Federal Penalties
Fine
Dec 12, 2025
$12,735
Ownership & Operations
Who Operates This Facility
Guadalupe County Hospital Board
for profit
TREATY HEALTHCARE INC
GABRIEL BARRAZA
Chain Affiliation
The Ensign Group
338 facilities nationwide
Chain avg rating: 2.9/5 · Rank 15 of 84
Ownership & Management
Owners
Guadalupe County Hospital Board
Owner · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
122 reviews from families & visitors
Official Website
Visit legendkyle.com
Medicare data downloads
Original nursing home datasets
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