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Nursing home report card · San Antonio, TX

Legend Oaks Healthcare and Rehabilitation - West S

222 Bertetti Dr, San Antonio, TX 78227

Call this home: (210) 673-1700

View this home on Medicare.gov ↗

Infection-control problems noted

Quick summary

About average Medicare rating

A 3-star overall rating is common. Compare staffing hours and recent citations with nearby homes, and visit before you decide.

Our summary of public Medicare records. It does not establish that this home harmed a particular resident. About this summary.

How recent is this information?
Medicare file prepared
Aug 1, 2026
Our record last updated
Oct 15, 2026
Last routine health inspection
Jan 29, 2026

These dates mean different things. A new file can include older inspections and staffing figures. Read about the dates.

Medicare ratings

One star is the lowest rating. Five stars is the highest. Ratings are a starting point—read the inspection findings too.

Overall rating
3out of 5

Combines inspection, staffing, and care measures.

About average for U.S. nursing homes

Health inspections
3out of 5

Based on problems found during health inspections.

About average for U.S. nursing homes

Nursing staff
3out of 5

Based on staffing levels and related measures.

About average for U.S. nursing homes

Health and care results
4out of 5

Based on reported health and care results.

Above average

What do the ratings and warnings mean?
Medicare ratings
One star is the lowest rating. Five stars is the highest. These are government ratings, not family reviews.
Inspection problems
Inspectors found that a home did not meet a care or safety rule. The official term is “deficiency.”
Abuse warning
Medicare has flagged the home because of abuse-related inspection findings. Read the findings and dates.
Nursing staff time
Average staff hours for each resident per day. This does not mean each resident gets that much one-to-one care.

Learn about the records and their limits →

At a glance

These numbers come from the records we have. Inspection problems are rules the home did not meet. The dates covered can differ.

Care and safety problems
20

Care, safety, and resident-rights issues on recent inspections

Fire-safety problems
0

Building, alarms, exits, and related safety citations

Reported fines
$8,632

Total fine amounts in the imported penalty records

Medicare file prepared
Aug 1, 2026

Medicare home ID: 676312

Inspection findings to read first

Start with these past findings. We show the most serious first, then the most recent. They do not describe the home’s condition today.

  • Immediate danger to residents · isolated case

    Apr 12, 2024 · Inspection rule 0689

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • Could have caused harm · pattern case

    Jun 12, 2026 · Inspection rule 0550

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • Could have caused harm · pattern case

    Jun 12, 2026 · Inspection rule 0609

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Read the inspection history →

Nursing staff time

These are average staff hours for each resident per day. They are not one-to-one bedside care. The file does not give the reporting period for each figure.

Registered nurses (RNs)
0.53hours per resident per day

about 32 minutes per resident per day

All nursing staff
3.64hours per resident per day

about 3 hr 38 min per resident per day

Registered nurse time on weekends
0.42hours per resident per day

about 25 minutes per resident per day

Latest inspection summary

A summary of the most recent routine inspections. You can open the dated findings below.

We do not have a routine inspection summary for this home. Check the dated findings below and the Medicare.gov record.

How this home compares

Compared with state and national averages. The numbers may cover different periods.

  • Overall CMS rating: 3 stars
  • Health inspection rating: 3 stars
  • Staffing rating: 3 stars
  • Registered nurse time per resident: 0.53 hours/day
  • Total nurse time per resident: 3.64 hours/day
See the dates used for these averages

Medicare file dates: this home Aug 1, 2026; Texas averages Unavailable; U.S. averages Oct 1, 2026.

Other concerns in the records

These points may be worth asking about. They do not establish what happened to a particular resident. See our Terms of Use.

  • Recent citations include infection-control problems
  • Inspectors have listed an unusually high number of problems
  • CMS has fined this home in the recent reporting period

How serious were the problems?

Inspectors rate each problem by how much harm it caused or could cause. We group the CMS letter codes into plain language.

  • Immediate danger to residents1 citation
  • Could have caused harm19 citations

Why inspectors showed up

Routine checks happen on a schedule. Complaint visits happen when someone reports a concern.

Complaints
0
Routine
20
Fire safety
0
Other
0

Who owns it

Names CMS lists as owners or managers · reported as For profit - Corporation.

  • We do not have individual owner names for this home.

Other homes in this group: All The Ensign Group nursing homes

Inspection history

Open a date to read what inspectors found. The harm labels explain how serious the problem was at the time.

June 12, 20262 findings
  • Freedom from Abuse, Neglect, and Exploitation problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0609 · code E

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • Resident Rights problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0550 · code E

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

April 23, 20262 findings
  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0690 · code D

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  • Infection Control problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0880 · code D

    Provide and implement an infection prevention and control program.

January 29, 20266 findings
  • Infection Control problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0880 · code E

    Provide and implement an infection prevention and control program.

  • Resident Rights problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0628 · code D

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  • Pharmacy Service problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0755 · code D

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • Resident Assessment and Care Planning problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0641 · code E

    Ensure each resident receives an accurate assessment.

  • Pharmacy Service problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0761 · code E

    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.

  • Nutrition and Dietary problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0812 · code E

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

December 9, 20251 finding
  • Infection Control problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0880 · code D

    Provide and implement an infection prevention and control program.

October 31, 20242 findings
  • Resident Rights problems
    Could have caused harm · widespread case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0576 · code F

    Ensure residents have reasonable access to and privacy in their use of communication methods.

  • Resident Assessment and Care Planning problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0657 · code D

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

April 12, 20242 findings
  • Quality of Life and Care problems
    Immediate danger to residents · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0689 · code J

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • Freedom from Abuse, Neglect, and Exploitation problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0609 · code D

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

September 15, 20235 findings
  • Nutrition and Dietary problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0812 · code D

    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 problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0644 · code D

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  • Resident Assessment and Care Planning problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0645 · code D

    PASARR screening for Mental disorders or Intellectual Disabilities

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0689 · code D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • Resident Assessment and Care Planning problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0638 · code D

    Assure that each resident’s assessment is updated at least once every 3 months.

Fines & penalties

These fines appear in Medicare’s records. A listed amount does not tell us whether it has been paid.

  • Fine · Apr 12, 2024$8,632

Other homes in this chain

The Ensign Group · other locations in Texas

Related topics

Questions about Legend Oaks Healthcare and Rehabilitation - West S

What is Legend Oaks Healthcare and Rehabilitation - West S's Medicare star rating?
As of August 1, 2026, Legend Oaks Healthcare and Rehabilitation - West S in San Antonio, Texas has an overall CMS rating of 3 out of 5 stars. Other CMS scores: health inspection 3 of 5, staffing 3 of 5, quality measures 4 of 5. These are CMS ratings based on inspection, staffing, and quality information, not consumer reviews.
Has Legend Oaks Healthcare and Rehabilitation - West S been fined?
As of August 1, 2026, the imported penalty records list $8,632 in reported fines for Legend Oaks Healthcare and Rehabilitation - West S. The individual penalty dates can differ from the Medicare file date; a listed fine does not establish that it was paid.
Does Legend Oaks Healthcare and Rehabilitation - West S have a Medicare abuse warning?
No. The current CMS Care Compare extract does not show an abuse warning icon for Legend Oaks Healthcare and Rehabilitation - West S in San Antonio, Texas.
How does Legend Oaks Healthcare and Rehabilitation - West S compare with other nursing homes in Texas?
Its overall CMS rating is 3 out of 5. A rating comparison is withheld because a matching source date or a usable rating is missing. Use the Texas report card and dated inspection history for context; inspection totals alone are not a like-for-like performance comparison.

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