Legend Oaks Healthcare and Rehabilitation - West SCMS ratings, inspections and fines
- Address
- 222 Bertetti Dr, San Antonio, TX 78227
- CCN
- 676312
- Ownership type
- For-profit, corporation
- Certified beds
- 124
- Chain
- The Ensign Group
- Residents per day
- 109
- CMS flags
- None in the CMS record
The watch list stays in this browser. After each CMS update, it shows the values that changed at the homes on the list.
CMS gives Legend Oaks Healthcare and Rehabilitation - West S an overall rating of 3 of 5 stars. The last standard survey was on 29 Jan 2026. The latest survey cycle has 11 health citations. The median for nursing homes in Texas is 8. CMS lists 1 fine of $8,632 for this home in its penalties file.
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is based on three individual domains, a change in any one of the domains can affect the overall rating. Any new data for a nursing home could potentially change a star rating domain.
Centers for Medicare & Medicaid Services, Five-Star Quality Rating System: Technical Users' Guide, July 2026. CMS processed this record on .
Since the last CMS update
The site has no recorded change for this home. In each CMS update, the site compares the ratings, the penalties and the citations of each home.
Ratings
CMS gives each home 1 to 5 stars for health inspections, for staffing and for quality measures, and one overall rating.
| Rating (1 to 5 stars) | This home | Bexar County median | Texas median | US average (CMS) |
|---|---|---|---|---|
| Overall rating | 3 | 2.0 | 3.0 | 3.0 |
| Health inspection rating | 3 | 2.0 | 3.0 | 2.8 |
| Staffing rating | 3 | 2.0 | 2.0 | 2.9 |
| Quality measure rating | 4 | 4.0 | 4.0 | 3.6 |
A median is the middle value of the homes in the group: 62 homes in the county, 1,177 homes in the state. What the CMS star ratings measure
Citations by survey cycle
CMS keeps the last three cycles, and cycle 1 is the latest. A cycle has one standard survey. Citations from complaint and infection control inspections go into cycles of 12 months.
| Survey cycle | Standard survey | Citations | Texas median |
|---|---|---|---|
| Cycle 1 (latest) | 29 Jan 2026 | 11 | 8 |
| Cycle 2 | 31 Oct 2024 | 2 | 8 |
| Cycle 3 | No date | 7 | 8 |
Health citations
The record of one deficiency in an inspection. One inspection can give many citations.
Scope and severity. A letter from A to L on each citation. Scope is the number of residents that the deficiency affected. Severity is the level of harm.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | K0 | L0 | |
| Actual harm that is not immediate jeopardy | G0 | H0 | I0 |
| No actual harm, potential for more than minimal harm | |||
| No actual harm, potential for minimal harm | A0 | B0 | C0 |
Survey cycle 1 (latest): 11 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 12 Jun 2026 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E | Complaint investigation | 3 Jul 2026 |
| 12 Jun 2026 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | E | Complaint investigation | 3 Jul 2026 |
| 23 Apr 2026 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Complaint investigation | 14 May 2026 |
| 23 Apr 2026 | F0880 | Provide and implement an infection prevention and control program. | D | Complaint investigation | 14 May 2026 |
| 29 Jan 2026 | F0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D | Standard survey | 18 Feb 2026 |
| 29 Jan 2026 | F0641 | Ensure each resident receives an accurate assessment. | E | Standard survey | 18 Feb 2026 |
| 29 Jan 2026 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard survey | 18 Feb 2026 |
| 29 Jan 2026 | F0761 | 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. | E | Standard survey | 18 Feb 2026 |
| 29 Jan 2026 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard survey | 18 Feb 2026 |
| 29 Jan 2026 | F0880 | Provide and implement an infection prevention and control program. | E | Standard survey | 18 Feb 2026 |
| 9 Dec 2025 | F0880 | Provide and implement an infection prevention and control program. | D | Complaint investigation | 10 Dec 2025 |
Survey cycle 2: 2 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 31 Oct 2024 | F0576 | Ensure residents have reasonable access to and privacy in their use of communication methods. | F | Standard survey | 22 Nov 2024 |
| 31 Oct 2024 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard survey | 22 Nov 2024 |
Survey cycle 3: 7 citations
The CMS provider file has no standard survey date for this cycle.
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 12 Apr 2024 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 15 Apr 2024 |
| 12 Apr 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | Complaint investigation | 15 Apr 2024 |
| 15 Sep 2023 | F0638 | Assure that each resident’s assessment is updated at least once every 3 months. | D | Standard survey | 12 Oct 2023 |
| 15 Sep 2023 | F0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | Standard survey | 12 Oct 2023 |
| 15 Sep 2023 | F0645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Standard survey | 12 Oct 2023 |
| 15 Sep 2023 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 12 Oct 2023 |
| 15 Sep 2023 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D | Standard survey | 12 Oct 2023 |
The requirement text is the CMS summary of the F-tag. It is not the report of the surveyor. How to read an inspection report
Penalties
A fine, or a payment denial: a period in which Medicare or Medicaid does not pay for new admissions. The CMS penalties file holds three years.
| Date | Type | Fine | Days without payment |
|---|---|---|---|
| 12 Apr 2024 | Fine | $8,632 |
Staffing
Hours per resident per day. The nurse hours for one resident on an average day. CMS calculates the figure from the hours that the home reports for a quarter.
| Staff | This home | Texas median | Texas average (CMS) |
|---|---|---|---|
| All nurse staff | 3.64 | 3.30 | 3.39 |
| Registered nurses (RN) | 0.53 | 0.40 | 0.43 |
| Licensed practical nurses (LPN) | 0.99 | 0.95 | |
| Nurse aides | 2.12 | 2.00 | |
| All nurse staff, weekends | 3.20 | 2.90 | 2.98 |
- Nurse staff turnover in a year
- 20.7%
- Nurse staff turnover, Texas median
- 52.1%
- RN turnover in a year
- 18.2%
- Administrators who left in a year
- 0
Homes report the hours to CMS in the Payroll-Based Journal.
Quality measures
A figure that CMS calculates from the assessments of residents. One example is the percentage of long-stay residents with a fall and a major injury.
| Measure (CMS text) | Residents | This home | Texas median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 12.9% | 14.9% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | 0.0% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 3.1% | 0.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.0% | 3.0% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.3% | 0.7% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 36.3% | 12.4% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 1.6% | 3.4% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 3.6% | 8.3% | 13.4% |
For each measure in this table, CMS gives more points in the quality measure rating for a lower percentage. The site calculates the medians from the CMS file. What the CMS star ratings measure
Ownership
An organisation in the CMS ownership file. CMS records its role, for example an ownership interest, operational or managerial control, or a mortgage interest.
- Ownership type
- For-profit, corporation
- Legal business name
- Dewitt Medical District
- Chain
- The Ensign Group (342 homes in the CMS chain file)
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Dewitt Medical District | 5% or greater indirect ownership interest | 100% | 1 Apr 2017 |
| Bertetti Healthcare, Inc. | Operational/managerial control | 1 Apr 2017 | |
| Bertetti Healthcare, Inc. | Adp of the snf | 24 Oct 2025 | |
| Ensign Services Inc | Adp of the snf | 1 May 2016 | |
| National Health Investors, Inc. | Adp of the snf | 1 Apr 2017 | |
| Texas Nhi Investors, LLC | Adp of the snf | 1 Apr 2017 |
The site shows organisations only. It does not show the names of persons.
Other homes in Bexar County
| Nursing home | City | Overall rating | Citations, latest cycle | Fines | Last standard survey | |
|---|---|---|---|---|---|---|
| The Mission at Blue Skies of Texas East | San Antonio | 5 of 5 | 7 | $17,345 | 11 Jul 2025 | |
| Lakeside Nursing and Rehabilitation Center | San Antonio | 5 of 5 | 6 | $14,611 | 31 Jul 2025 | |
| Westover Hills Rehabilitation and Healthcare | San Antonio | 4 of 5 | 12 | $20,156 | 12 Jun 2026 | |
| Windemere at Westover Hills | San Antonio | 2 of 5 | 5 | $8,281 | 19 Dec 2025 | |
| Harbor Valley Health and Rehabilitation | San Antonio | 2 of 5 | 17 | $18,989 | 5 Dec 2025 | |
| Las Colinas of Westover | San Antonio | 2 of 5 | 15 | $38,630 | 3 Dec 2025 | |
| Silver Creek Nursing and Rehabilitation | San Antonio | 3 of 5 | 6 | $0 | 2 Jul 2025 | |
| San Antonio West Nursing and Rehabilitation | San Antonio | 1 of 5 | 37 | $364,695 | 10 Apr 2026 | |
| Inspiration Hills Rehabilitation Center | San Antonio | 3 of 5 | 13 | $0 | 4 Jun 2026 | |
| Avir at San Antonio | San Antonio | 1 of 5 | 24 | $29,494 | 30 Aug 2025 | |
| Legend Oaks Healthcare and Rehabilitation Center - | San Antonio | 3 of 5 | 15 | $0 | 4 Dec 2025 | |
| The Sarah Roberts French Home | San Antonio | 2 of 5 | 4 | $0 | 5 Feb 2026 |
Official channels
- Care Compare record of this nursing homeMedicare.gov. The official CMS record of this home.
- Texas Health and Human Services: complaint and incident intakeThe complaint page of the State Survey Agency for Texas, from the CMS list of agencies.
- Contact information for State Survey AgenciesCMS. The web address and the telephone number of the State Survey Agency of each state. These agencies investigate complaints about nursing homes.
- Filing a complaintMedicare.gov. The page names the State Survey Agency as the place for a complaint about nursing home care or facility conditions.
- Eldercare LocatorAdministration for Community Living. A public service that connects older adults and their families to local services. Telephone: 1-800-677-1116.
Cite this page
Centers for Medicare & Medicaid Services, Care Compare. Record of Legend Oaks Healthcare and Rehabilitation - West S (CCN 676312). Data processed 1 Aug 2026. Elder Care Record, https://eldercarerecord.com/facility/legend-oaks-healthcare-and-rehabilitation-west-s-san-antonio-tx-676312/
Provenance
- Licence
- US government work, public domain
- CMS processed the data on
A program makes this page from the CMS files, and the same files always give the same text. How the site makes the figures. Report an error.
Questions
- When was Legend Oaks Healthcare and Rehabilitation - West S last inspected?
- The latest inspection with a citation in the CMS record was on 12 Jun 2026. It was a complaint investigation. It gave 2 citations. The standard survey before the last one was on 31 Oct 2024.
- Who operates Legend Oaks Healthcare and Rehabilitation - West S?
- The CMS record gives the ownership type as for-profit, corporation. CMS lists the home in the chain The Ensign Group. The CMS ownership file names Bertetti Healthcare, Inc. for operational or managerial control. This site does not show the names of persons.
- Is Legend Oaks Healthcare and Rehabilitation - West S a Special Focus Facility?
- No. The CMS provider file lists no Special Focus status for this home. CMS lists 6 homes in Texas as Special Focus Facilities and 30 as candidates.
- Where does the data on this page come from?
- The data comes from the CMS Care Compare files for nursing homes. CMS processed the files on 1 Aug 2026. The Care Compare record on Medicare.gov is the official record of the home.