nursing home in San Antonio, TX
Legend Oaks Healthcare and Rehabilitation - West S
222 Bertetti Dr, San Antonio, TX 78227 · (210) 673-1700
CMS overall star rating
- Health inspections★★★★★3
- Staffing★★★★★3
- Quality measures★★★★★4
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Legend Oaks Healthcare and Rehabilitation - West S at a glance
Legend Oaks Healthcare and Rehabilitation - West S is a 124-bed for-profit nursing home in San Antonio, Texas (Bexar County).
CMS gives it 3 out of 5 stars on its overall star rating, close to the Texas average of 2.7.
Residents receive about 3.6 hours of nursing care per day (0.5 of them from registered nurses), better than the state average of 3.4 hours.
Its most recent standard health inspection (January 29, 2026) found 11 health citations. The Texas average is 9.4.
Federal regulators fined it 1 time in the past three years, totaling $8,632.
Nursing staff turnover is 20.7% per year (state average 55.3%).
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Corporation
- Beds
- 124
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- The Ensign Group
- Medicare-certified since
- May 31, 2012
- Resident/family council
- Resident
- County
- Bexar County
- CMS Certification Number
- 676312
Ratings
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 3 / 5 | 2.7 / 5 | 3 / 5 | Average |
| Health inspection rating ⓘ (higher is better) | 3 / 5 | 2.8 / 5 | 2.8 / 5 | Average |
| Staffing rating ⓘ (higher is better) | 3 / 5 | 1.9 / 5 | 2.9 / 5 | Average |
| Quality measures rating ⓘ (higher is better) | 4 / 5 | 3.7 / 5 | 3.6 / 5 | Average |
| Long-stay quality rating (higher is better) | 4 / 5 | 4 / 5 | 3.8 / 5 | Average |
| Short-stay (rehab) quality rating (higher is better) | 5 / 5 | 3.2 / 5 | 3.3 / 5 | Better |
Staffing
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 3.64 hrs | 3.39 hrs | 3.86 hrs | Worse |
| Registered nurse hours per resident per day (higher is better) | 0.53 hrs | 0.43 hrs | 0.69 hrs | Worse |
| Nurse aide hours per resident per day (higher is better) | 2.12 hrs | 2.01 hrs | 2.32 hrs | Worse |
| Weekend nurse staff hours per resident per day (higher is better) | 3.20 hrs | 2.98 hrs | 3.42 hrs | Worse |
| Nursing staff turnover (yearly) (lower is better) | 20.7% | 55.3% | 45.8% | Better |
| Registered nurse turnover (yearly) (lower is better) | 18.2% | 54.6% | 42.9% | Better |
| Administrators who left in the past year (lower is better) | 0 | 1 | 1 | Better |
Inspections
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 11 | 9 | 9 | Worse |
| Citations from complaint investigations (latest cycle) (lower is better) | 5 | 4 | 3 | Worse |
| Weighted health inspection score ⓘ (lower is better) | 75.8 | 102 | 80.6 | Better |
Penalties
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 1 | 1 | 1 | Worse |
| Total fines in the past 3 years (lower is better) | $8,632 | $44,141 | $30,972 | Better |
| All federal penalties in the past 3 years (lower is better) | 1 | 2 | 1 | Average |
Size
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 124 | 113 | 107 | |
| Average residents per day | 109 | 76 | 86 | |
| Occupancy | 87.7% | 67.6% | 80.9% |
Long-stay residents
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 0% | 3.3% | 3.2% | Better |
| Long-stay residents with pressure ulcers (lower is better) | 1.6% | 3.8% | 4.6% | Better |
| Long-stay residents given antipsychotic medication (lower is better) | 3.6% | 9.6% | 15.4% | Better |
| Long-stay residents with a urinary tract infection (lower is better) | 3.1% | 0.8% | 1.6% | Worse |
| Long-stay residents with a catheter left in the bladder (lower is better) | 0% | 0.3% | 0.8% | Better |
| Long-stay residents needing more help with daily activities (lower is better) | 12.9% | 15.8% | 13.9% | Better |
| Long-stay residents whose walking worsened (lower is better) | 36.3% | 14% | 14.1% | Worse |
| Long-stay residents who lose too much weight (lower is better) | 3.9% | 3% | 5.2% | Better |
| Long-stay residents with depressive symptoms (lower is better) | 3.9% | 2.4% | 12.8% | Better |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 11.9% | 18% | 19.5% | Better |
| Long-stay residents with new or worse incontinence (lower is better) | 14.2% | 13.4% | 19% | Better |
| Long-stay residents given a flu vaccine (higher is better) | 100% | 98% | 95.5% | Average |
| Long-stay residents given a pneumonia vaccine (higher is better) | 99.7% | 96.6% | 93.6% | Better |
Short-stay residents
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents newly given antipsychotic medication (lower is better) | 0.3% | 1.5% | 1.6% | Better |
| Short-stay residents given a flu vaccine (higher is better) | 98.1% | 88% | 79.8% | Better |
| Short-stay residents given a pneumonia vaccine (higher is better) | 99% | 88.9% | 82% | Better |
Inspection citations
State inspectors cited this home for 20 health deficiencies and 3 fire safety deficiencies in the inspection records CMS currently publishes. 1 citation involved actual harm, including 1 rated "immediate jeopardy".
| Date | Citation | Severity | Status |
|---|---|---|---|
| June 12, 2026 Complaint | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | E Potential harm, pattern | Corrected July 3, 2026 |
| June 12, 2026 Complaint | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Tag F0550 | E Potential harm, pattern | Corrected July 3, 2026 |
| April 23, 2026 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected May 14, 2026 |
| April 23, 2026 Complaint | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Tag F0690 | D Potential harm, isolated | Corrected May 14, 2026 |
| January 29, 2026 Fire safety | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Tag K0741 | E Potential harm, pattern | Corrected February 18, 2026 |
| January 29, 2026 Fire safety | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Tag K0211 | D Potential harm, isolated | Corrected February 18, 2026 |
| January 29, 2026 Standard | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Tag F0641 | E Potential harm, pattern | Corrected February 18, 2026 |
| January 29, 2026 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected February 18, 2026 |
| January 29, 2026 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | E Potential harm, pattern | Corrected February 18, 2026 |
| January 29, 2026 Standard | 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. Pharmacy Service Deficiencies · Tag F0761 | E Potential harm, pattern | Corrected February 18, 2026 |
| January 29, 2026 Standard | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Tag F0628 | D Potential harm, isolated | Corrected February 18, 2026 |
| January 29, 2026 Standard | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | D Potential harm, isolated | Corrected February 18, 2026 |
| December 9, 2025 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected December 10, 2025 |
| October 31, 2024 Fire safety | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Tag K0372 | E Potential harm, pattern | Corrected November 22, 2024 |
| October 31, 2024 Standard | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · Tag F0576 | F Potential harm, widespread | Corrected November 22, 2024 |
| October 31, 2024 Standard | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Tag F0657 | D Potential harm, isolated | Corrected November 22, 2024 |
| April 12, 2024 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | J Immediate jeopardy, isolated | Corrected April 15, 2024 |
| April 12, 2024 Complaint | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Corrected April 15, 2024 |
| September 15, 2023 Standard | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Tag F0644 | D Potential harm, isolated | Corrected October 12, 2023 |
| September 15, 2023 Standard | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Tag F0638 | D Potential harm, isolated | Corrected October 12, 2023 |
| September 15, 2023 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | D Potential harm, isolated | Corrected October 12, 2023 |
| September 15, 2023 Standard | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected October 12, 2023 |
| September 15, 2023 Standard | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Tag F0645 | D Potential harm, isolated | Corrected October 12, 2023 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports 1 federal penalty in the past three years, including $8,632 in fines.
| Date | Penalty | Amount / length |
|---|---|---|
| April 12, 2024 | Fine | $8,632 |
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| DEWITT MEDICAL DISTRICT Organization | 5% or greater indirect ownership interest | 100% | 04/01/2017 |
| BERTETTI HEALTHCARE, INC. Organization | adp of the snf | NOT APPLICABLE | 10/24/2025 |
| ENSIGN SERVICES INC Organization | adp of the snf | NOT APPLICABLE | 05/01/2016 |
| GRAY, ROBERT Individual | adp of the snf | NOT APPLICABLE | 12/15/2017 |
| MANSOOR, SAAD Individual | adp of the snf | NOT APPLICABLE | 09/12/2023 |
| NATIONAL HEALTH INVESTORS, INC. Organization | adp of the snf | NOT APPLICABLE | 04/01/2017 |
| TEXAS NHI INVESTORS, LLC Organization | adp of the snf | NOT APPLICABLE | 04/01/2017 |
| ALEXANDER, ALMA Individual | corporate officer | NOT APPLICABLE | 05/27/2020 |
| BURNAM, SOON Individual | corporate officer | NOT APPLICABLE | 04/01/2017 |
| KEETCH, CHAD Individual | corporate officer | NOT APPLICABLE | 03/01/2011 |
| GRAY, ROBERT Individual | managing control - governing body | NOT APPLICABLE | 12/15/2017 |
| MANSOOR, SAAD Individual | managing control - governing body | NOT APPLICABLE | 09/12/2023 |
| BERTETTI HEALTHCARE, INC. Organization | operational/managerial control | NOT APPLICABLE | 04/01/2017 |
| GRAY, ROBERT Individual | operational/managerial control | NOT APPLICABLE | 12/15/2017 |
| MANSOOR, SAAD Individual | operational/managerial control | NOT APPLICABLE | 09/12/2023 |
Other nursing homes near Legend Oaks Healthcare and Rehabilitation - West S
The Mission at Blue Skies of Texas East
4949 Ravenswood Drive, San Antonio, TX 78227 · 1.2 mi
Non-profit · 80 beds
- CMS high performer
★★★★★5Much above averageLakeside Nursing and Rehabilitation Center
8707 Lakeside Parkway, San Antonio, TX 78245 · 2.3 mi
Government · 118 beds · Part of The Ensign Group
★★★★★5Much above averageWestover Hills Rehabilitation and Healthcare
9922 State Hwy. 151, San Antonio, TX 78251 · 3.7 mi
Government · 124 beds · Part of The Ensign Group
★★★★★4Above averageWindemere at Westover Hills
11106 Christus Hills, San Antonio, TX 78251 · 4.2 mi
For-profit · 112 beds · Part of Cantex Continuing Care
★★★★★2Below averageHarbor Valley Health and Rehabilitation
6211 Old Pearsall Rd, San Antonio, TX 78242 · 4.4 mi
For-profit · 120 beds · Part of Fannin County Hospital District
- Abuse citation
★★★★★2Below averageLas Colinas of Westover
9738 Westover Hills Blvd, San Antonio, TX 78251 · 4.9 mi
For-profit · 140 beds · Part of Caring Healthcare Group
★★★★★2Below average
Frequently asked questions
What is Legend Oaks Healthcare and Rehabilitation - West S's rating?
Legend Oaks Healthcare and Rehabilitation - West S has 3 out of 5 stars on the CMS overall star rating. The average for Texas nursing homes is 2.7 stars.
How many inspection citations did Legend Oaks Healthcare and Rehabilitation - West S receive?
Its most recent standard health inspection found 11 citations, compared with a Texas average of 9.4. Every citation is listed on this page with its severity.
Does Legend Oaks Healthcare and Rehabilitation - West S accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Legend Oaks Healthcare and Rehabilitation - West S?
It is for profit - corporation and part of The Ensign Group. The ownership section on this page lists the owners and managers reported to CMS.
Where is Legend Oaks Healthcare and Rehabilitation - West S and how do I contact it?
Legend Oaks Healthcare and Rehabilitation - West S is at 222 Bertetti Dr, San Antonio, TX 78227. Phone: (210) 673-1700.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.