Nursing Home Record

For profit - Corporation · 124 certified beds · CMS number 676312

Legend Oaks Healthcare and Rehabilitation - West S, San Antonio, TX

CMS records 20 health deficiencies at Legend Oaks Healthcare and Rehabilitation - West S in San Antonio, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Jan 29, 2026. The highest severity cited is J (immediate jeopardy to resident health or safety). 1 citation was at the immediate jeopardy level. CMS lists 1 fine totaling $8,632 in the last three years.

Inspections and deficiencies

CMS findings for Legend Oaks Healthcare and Rehabilitation - West S 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 - West S may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare

Most recent cycle (11 deficiencies)

Standard inspection Jan 29, 2026. CMS counts 11 health deficiencies and 2 fire safety deficiencies in this cycle.

Jun 12, 2026 · Complaint inspection

2 deficiencies, highest E

F609 · Reporting suspected abuse and crimes

Requirement cited (CMS): Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Severity
E No actual harm, potential for more than minimal harm, pattern
Status
Correction date Jul 3, 2026

F550 · Dignity and the right to exercise rights

Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Severity
E No actual harm, potential for more than minimal harm, pattern
Status
Correction date Jul 3, 2026

Apr 23, 2026 · Complaint inspection

2 deficiencies, highest D

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 May 14, 2026

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 May 14, 2026

Jan 29, 2026 · Standard inspection

6 deficiencies, highest E

F880 · Infection prevention and control program

Requirement cited (CMS): Provide and implement an infection prevention and control program.

Severity
E No actual harm, potential for more than minimal harm, pattern
Status
Correction date Feb 18, 2026

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 Feb 18, 2026

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
E No actual harm, potential for more than minimal harm, pattern
Status
Correction date Feb 18, 2026

F755 · Pharmacy services and a consultant pharmacist

Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Severity
D No actual harm, potential for more than minimal harm, isolated
Status
Correction date Feb 18, 2026

F641 · Accurate resident assessments

Requirement cited (CMS): Ensure each resident receives an accurate assessment.

Severity
E No actual harm, potential for more than minimal harm, pattern
Status
Correction date Feb 18, 2026

F628 · Discharge paperwork, notices, and bed-hold information

Requirement cited (CMS): Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Severity
D No actual harm, potential for more than minimal harm, isolated
Status
Correction date Feb 18, 2026

Dec 9, 2025 · Complaint inspection

1 deficiency, highest D

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 Dec 10, 2025
Previous cycle: 2 deficiencies (standard inspection Oct 31, 2024)

Standard inspection Oct 31, 2024. CMS counts 2 health deficiencies and 1 fire safety deficiency in this cycle.

Oct 31, 2024 · Standard inspection

2 deficiencies, highest F

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 Nov 22, 2024

F576 · Phone, mail, and internet access

Requirement cited (CMS): Ensure residents have reasonable access to and privacy in their use of communication methods.

Severity
F No actual harm, potential for more than minimal harm, widespread
Status
Correction date Nov 22, 2024
Earlier cycle: 7 deficiencies (standard inspection Sep 15, 2023)

Standard inspection Sep 15, 2023. CMS counts 7 health deficiencies and 0 fire safety deficiencies in this cycle.

Apr 12, 2024 · Complaint inspection

2 deficiencies, highest J

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
J Immediate jeopardy to resident health or safety, isolated
Status
Correction date Apr 15, 2024

F609 · Reporting suspected abuse and crimes

Requirement cited (CMS): Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Severity
D No actual harm, potential for more than minimal harm, isolated
Status
Correction date Apr 15, 2024

Sep 15, 2023 · Standard inspection

5 deficiencies, highest D

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 Oct 12, 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 Oct 12, 2023

F645 · Pre-admission screening for mental disorder or intellectual disability

Requirement cited (CMS): PASARR screening for Mental disorders or Intellectual Disabilities

Severity
D No actual harm, potential for more than minimal harm, isolated
Status
Correction date Oct 12, 2023

F644 · Coordinating with PASARR screening

Requirement cited (CMS): Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Severity
D No actual harm, potential for more than minimal harm, isolated
Status
Correction date Oct 12, 2023

F638 · Quarterly assessment reviews

Requirement cited (CMS): Assure that each resident’s assessment is updated at least once every 3 months.

Severity
D No actual harm, potential for more than minimal harm, isolated
Status
Correction date Oct 12, 2023

Tags cited in more than one inspection

4 tags cited on more than one inspection date at Legend Oaks Healthcare and Rehabilitation - West S; each date counts once and does not mean the same incident. PNC = past non-compliance.

TagInspectionsDates
F880 Infection prevention and control program3Apr 23, 2026; Jan 29, 2026; Dec 9, 2025
F609 Reporting suspected abuse and crimes2Jun 12, 2026; Apr 12, 2024
F689 Accident prevention and supervision2Apr 12, 2024; Sep 15, 2023
F812 Food safety and sanitation2Jan 29, 2026; Sep 15, 2023

Fines and payment denials

DateTypeAmount / length
Apr 12, 2024Fine$8,632

Staffing and CMS ratings

Total nurse staff hours per resident per day
3.64 h (above the Texas median of 3.27 h)
RN hours per resident per day
0.53 h (above the Texas median of 0.38 h)
Weekend nurse staff hours per resident per day
3.20 h
Nursing staff turnover
20.7% (Texas median 52.1%)
Administrators who left
0
CMS overall rating
3 of 5
Health inspection rating
3 of 5
Staffing rating
3 of 5
Quality measure rating
4 of 5

CMS figures for Legend Oaks Healthcare and Rehabilitation - West S, copied as published; Texas medians are ours.

Facility details

Address
222 Bertetti Dr, San Antonio, TX 78227
Phone
(210) 673-1700
County
Bexar
Accepts
Medicare and Medicaid
Ownership
For profit - Corporation
Chain (CMS)
The Ensign Group
Certified beds
124
Average residents per day
108.8
In Medicare/Medicaid since
May 31, 2012
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.

  • How do staff track and report infections among residents? (F880, cited 3 times)
  • Who at the home is responsible for reporting incidents to the state? (F609, cited 2 times)
  • How does the home assess each resident's fall risk and plan to prevent falls? (F689, cited 2 times)
  • When was the kitchen last inspected, and how are food temperatures checked? (F812, cited 2 times)

Other nursing homes in San Antonio and the same chain

Source

CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.

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