For profit - Individual · 126 certified beds · CMS number 676113
Legend Oaks Healthcare and Rehabilitation Center -, San Antonio, TX
CMS records 32 health deficiencies at Legend Oaks Healthcare and Rehabilitation Center - in San Antonio, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Dec 4, 2025. The highest severity cited is F (no actual harm, potential for more than minimal harm). CMS lists no fines or payment denials in the last three years.
- 32deficiencies, 3 cycles (TX median 25)
- 15in the latest cycle (TX median 8)
- Fhighest severity · Potential for harm
- $0fines, last 3 years
- 3CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Legend Oaks Healthcare and Rehabilitation Center - as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Legend Oaks Healthcare and Rehabilitation Center - may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (15 deficiencies)
Standard inspection Dec 4, 2025. CMS counts 15 health deficiencies and 2 fire safety deficiencies in this cycle.
May 15, 2026 · Complaint inspection
7 deficiencies, highest D
F805 · Food prepared for individual needs
Requirement cited (CMS): Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 16, 2026
F693 · Feeding tube use and care
Requirement cited (CMS): Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
- Severity
- B No actual harm, potential for minimal harm, pattern
- Status
- Correction date May 16, 2026
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 16, 2026
F583 · Personal privacy and confidential records
Requirement cited (CMS): Keep residents' personal and medical records private and confidential.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 16, 2026
F577 · Seeing inspection results
Requirement cited (CMS): Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
- Severity
- B No actual harm, potential for minimal harm, pattern
- Status
- Correction date May 16, 2026
F573 · Access to personal and medical records
Requirement cited (CMS): Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 16, 2026
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 16, 2026
Dec 4, 2025 · Standard inspection
8 deficiencies, highest E
F842 · Complete, confidential medical records
Requirement cited (CMS): Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 30, 2025
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 30, 2025
F761 · Drug labeling and secure storage
Requirement cited (CMS): Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 30, 2025
F759 · Medication error rate under 5 percent
Requirement cited (CMS): Ensure medication error rates are not 5 percent or greater.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 30, 2025
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Dec 30, 2025
F641 · Accurate resident assessments
Requirement cited (CMS): Ensure each resident receives an accurate assessment.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 30, 2025
F583 · Personal privacy and confidential records
Requirement cited (CMS): Keep residents' personal and medical records private and confidential.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 30, 2025
F554 · Taking one's own medications
Requirement cited (CMS): Allow residents to self-administer drugs if determined clinically appropriate.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 30, 2025
Previous cycle: 8 deficiencies (standard inspection Sep 27, 2024)
Standard inspection Sep 27, 2024. CMS counts 8 health deficiencies and 3 fire safety deficiencies in this cycle.
Sep 27, 2024 · Standard inspection
8 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 20, 2024
F849 · Hospice services
Requirement cited (CMS): Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 20, 2024
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 20, 2024
F700 · Bed rail safety
Requirement cited (CMS): Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 20, 2024
F698 · Dialysis care
Requirement cited (CMS): Provide safe, appropriate dialysis care/services for a resident who requires such services.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 20, 2024
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 20, 2024
F655 · Baseline care plan within 48 hours
Requirement cited (CMS): Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 20, 2024
F578 · Refusing treatment and advance directives
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 20, 2024
Earlier cycle: 9 deficiencies (standard inspection Jul 28, 2023)
Standard inspection Jul 28, 2023. CMS counts 9 health deficiencies and 0 fire safety deficiencies in this cycle.
Mar 22, 2024 · Complaint inspection
2 deficiencies, highest E
F790 · Dental care in skilled nursing facilities
Requirement cited (CMS): Provide routine and 24-hour emergency dental care for each resident.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 26, 2024
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 26, 2024
Jul 28, 2023 · Standard inspection
7 deficiencies, highest F
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Aug 16, 2023
F712 · Required physician visits
Requirement cited (CMS): Ensure that the resident and his/her doctor meet face-to-face at all required visits.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 16, 2023
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 16, 2023
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 16, 2023
F657 · Care plan timing and team review
Requirement cited (CMS): Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 16, 2023
F636 · Full assessment at admission and yearly
Requirement cited (CMS): Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 16, 2023
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 16, 2023
Tags cited in more than one inspection
5 tags cited on more than one inspection date at Legend Oaks Healthcare and Rehabilitation Center -; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F812 Food safety and sanitation | 3 | Dec 4, 2025; Sep 27, 2024; Jul 28, 2023 |
| F558 Accommodating individual needs and preferences | 2 | May 15, 2026; Jul 28, 2023 |
| F583 Personal privacy and confidential records | 2 | May 15, 2026; Dec 4, 2025 |
| F689 Accident prevention and supervision | 2 | May 15, 2026; Jul 28, 2023 |
| F690 Bladder, bowel, and catheter care | 2 | Dec 4, 2025; Sep 27, 2024 |
Fines and payment denials
CMS lists no fines or payment denials for this nursing home in the last three years.
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 3.62 h (above the Texas median of 3.27 h)
- RN hours per resident per day
- 0.42 h (above the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 3.17 h
- Nursing staff turnover
- 46.2% (Texas median 52.1%)
- Administrators who left
- 0
- CMS overall rating
- 3 of 5
- Health inspection rating
- 3 of 5
- Staffing rating
- 2 of 5
- Quality measure rating
- 4 of 5
CMS figures for Legend Oaks Healthcare and Rehabilitation Center -, copied as published; Texas medians are ours.
Facility details
- Address
- 2003 W Hutchins Place, San Antonio, TX 78224
- Phone
- (210) 927-0800
- County
- Bexar
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Individual
- Chain (CMS)
- The Ensign Group
- Certified beds
- 126
- Average residents per day
- 107.8
- In Medicare/Medicaid since
- Oct 10, 2006
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- When was the kitchen last inspected, and how are food temperatures checked? (F812, cited 3 times)
- How does the home adapt rooms and routines for residents with limited mobility, vision, or hearing? (F558, cited 2 times)
- How do staff protect residents' privacy during bathing, dressing, and treatments? (F583, cited 2 times)
- How does the home assess each resident's fall risk and plan to prevent falls? (F689, cited 2 times)
Other nursing homes in San Antonio and the same chain
- San Antonio West Nursing and Rehabilitation
San Antonio · 76 deficiencies - Parklane West Healthcare Center
San Antonio · 68 deficiencies - Castle Hills Rehabilitation and Care Center
San Antonio · 67 deficiencies - Crestway Nursing & Rehabilitation
San Antonio · 65 deficiencies - Oak Park Nursing and Rehabilitation Center
San Antonio · 60 deficiencies - Wurzbach Nursing and Rehabilitation
San Antonio · 58 deficiencies - The Eden of Las Colinas
Irving · 65 deficiencies - Northeast Rehabilitation and Healthcare Center
San Antonio · 57 deficiencies - Westpark Rehabilitation and Living
Euless · 54 deficiencies - Park Village Healthcare and Rehabilitation
DeSoto · 52 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.