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 ↗
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.
Combines inspection, staffing, and care measures.
About average for U.S. nursing homes
Based on problems found during health inspections.
About average for U.S. nursing homes
Based on staffing levels and related measures.
About average for U.S. nursing homes
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.
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, safety, and resident-rights issues on recent inspections
Building, alarms, exits, and related safety citations
Total fine amounts in the imported penalty records
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.
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.
about 32 minutes per resident per day
about 3 hr 38 min 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsImmediate 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsCould 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 problemsCould 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
- Northgate Plaza · Irving1 of 5 · 64 problems
- Heritage Gardens Rehabilitation and Healthcare · Carrollton1 of 5 · 25 problems
- Westpark Rehabilitation and Living · Euless1 of 5 · 54 problems
- The Chateau Waco · Waco1 of 5 · 31 problems
- Millbrook Healthcare and Rehabilitation Center · Lancaster1 of 5 · 27 problems
- Mesquite Post Acute Care · Lubbock1 of 5 · 41 problems
- Park Manor Bee Cave · Bee Cave1 of 5 · 37 problems
- Northeast Rehabilitation and Healthcare Center · San Antonio1 of 5 · 46 problems
Related topics
Questions about Legend Oaks Healthcare and Rehabilitation - West S
What is Legend Oaks Healthcare and Rehabilitation - West S's Medicare star rating?
Has Legend Oaks Healthcare and Rehabilitation - West S been fined?
Does Legend Oaks Healthcare and Rehabilitation - West S have a Medicare abuse warning?
How does Legend Oaks Healthcare and Rehabilitation - West S compare with other nursing homes in Texas?
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