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Legend Oaks Healthcare And Rehabilitation-Kyle

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About Legend Oaks Healthcare And Rehabilitation-Kyle

General Information

Legal Business NameLegend Oaks - Kyle, LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareFebruary 8, 2011 (6 years)
Capacity126
Residents116
Percent Occupied92%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsBoth
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Legend Oaks Healthcare And Rehabilitation-Kyle

Legend Oaks Healthcare And Rehabilitation-Kyle
was reviewed by Medicare to have a rating of 3 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Texas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

August 28, 2015 - 16 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmHealth InspectionMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
BSomePotential for Minimal HarmHealth InspectionDispose of garbage and refuse properly.

August 25, 2015 - 16 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.

June 12, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaint+InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth Inspection1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day.
ESomePotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.

June 11, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionA fire alarm system that can be heard throughout the facility.
ESomePotential for HarmFire Safety InspectionExits that are accessible at all times.

June 2, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaint+InspectionKeep all essential equipment working safely.

December 17, 2013 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

September 20, 2013 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$2,500 fine
---Fine$5,000 fine

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Legend Oaks Healthcare And Rehabilitation-Kyle require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 5min
2hr 30min
ReportedExpected
CNA
45min
40min
ReportedExpected
LPN
45min
1hr 5min
ReportedExpected
RN
3hr 40min
4hr 20min
ReportedExpected
Total Nursing

This facility also provides approximately 25min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

98.8%
94.9%
94.9%
90.7%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Seasonal Influenza Vaccine
100.0%
97.9%
82.8%
87.9%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
67.4%
70.6%
63.8%
46.9%
Q1 2015Q2 2015Q3 2015TX
Low Risk Residents Who Lose Control of Their Bowel or Bladder
19.0%
15.4%
13.6%
22.3%
Q1 2015Q2 2015Q3 2015TX
Received an Antipsychotic Medication
21.1%
17.1%
21.2%
19.6%
Q1 2015Q2 2015Q3 2015TX
Need for Help with ADLs has Increased
-
-
17.4%
8.8%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Self Report Moderate to Severe Pain
4.6%
3.2%
3.3%
6.3%
Q1 2015Q2 2015Q3 2015TX
Lose Too Much Weight
4.8%
3.1%
6.2%
6.6%
Q1 2015Q2 2015Q3 2015TX
High Risk Residents With Pressure Ulcers
1.1%
0.0%
1.1%
6.1%
Q1 2015Q2 2015Q3 2015TX
Have Depressive Symptoms
0.0%
0.0%
0.0%
5.1%
Q1 2015Q2 2015Q3 2015TX
With a Urinary Tract Infection
4.4%
1.0%
3.2%
3.5%
Q1 2015Q2 2015Q3 2015TX
Experiencing One or More Falls with Major Injury
3.3%
1.1%
2.1%
3.3%
Q1 2015Q2 2015Q3 2015TX
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.6%
Q1 2015Q2 2015Q3 2015TX
Were Physically Restrained

Quality Measures for Short Stay Residents

95.2%
91.9%
90.4%
71.4%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
96.7%
95.2%
95.2%
71.1%
Q1 2015Q2 2015Q3 2015TX
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
12.4%
17.9%
13.0%
16.5%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
6.7%
2.9%
3.9%
3.2%
Q1 2015Q2 2015Q3 2015TX
Newly Received an Antipsychotic Medication
0.7%
2.1%
2.8%
1.0%
Q1 2015Q2 2015Q3 2015TX
With Pressure Ulcers That Are New or Worsened