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Legend Oaks Healthcare and Rehabilitation Center -
2003 W Hutchins Place, San Antonio, TX 78224 (opens Google Maps) · Bexar County · (210) 927-0800· 126 certified beds · avg 108 residents/day · certified since Oct 10, 2006 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
3/5
Health inspection rating (on-site)
inspected Dec 4, 2025
0
Serious findings on record
$0
Fines, last 3 years
3.20
Nurse hours/resident/day (adjusted)
Every record stays on this page.
What health inspectors found (on-site government inspections — the most independent evidence available)
New to these records? How to read an inspection report →
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5 · how star ratings work →
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and quality measures from resident assessments and claims.
Inspection findings in the public record
Showing the latest 3 of 32 inspection findings. Open the full record below to read every finding.
The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint F-0558
The facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint F-0573
The facility did not keep residents' personal and medical information private and confidential. · from a complaint F-0583
View all 32 inspection findingsShow only the latest 3 findings
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 15, 2026 | D · Potential for more than minimal harm, isolated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint · F-0558 |
| May 15, 2026 | D · Potential for more than minimal harm, isolated | The facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint · F-0573 |
| May 15, 2026 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' personal and medical information private and confidential. · from a complaint · F-0583 |
| May 15, 2026 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| May 15, 2026 | D · Potential for more than minimal harm, isolated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint · F-0805 |
| May 15, 2026 | B · Potential for minimal harm, pattern | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. · from a complaint · F-0577 |
| May 15, 2026 | B · Potential for minimal harm, pattern | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint · F-0693 |
| Dec 4, 2025 | E · Potential for more than minimal harm, pattern | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · F-0690 |
| Dec 4, 2025 | D · Potential for more than minimal harm, isolated | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · F-0554 |
| Dec 4, 2025 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' personal and medical information private and confidential. · F-0583 |
| Dec 4, 2025 | D · Potential for more than minimal harm, isolated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| Dec 4, 2025 | D · Potential for more than minimal harm, isolated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · F-0759 |
| Dec 4, 2025 | D · Potential for more than minimal harm, isolated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761 |
| Dec 4, 2025 | D · Potential for more than minimal harm, isolated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Dec 4, 2025 | D · Potential for more than minimal harm, isolated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · F-0842 |
| Sep 27, 2024 | E · Potential for more than minimal harm, pattern | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · F-0655 |
| Sep 27, 2024 | E · Potential for more than minimal harm, pattern | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · F-0700 |
| Sep 27, 2024 | E · Potential for more than minimal harm, pattern | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Sep 27, 2024 | D · Potential for more than minimal harm, isolated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · F-0578 |
| Sep 27, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · F-0690 |
| Sep 27, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698 |
| Sep 27, 2024 | D · Potential for more than minimal harm, isolated | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · F-0849 |
| Sep 27, 2024 | D · Potential for more than minimal harm, isolated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Mar 22, 2024 | E · Potential for more than minimal harm, pattern | The facility did not provide routine dental care and 24-hour emergency dental care for residents. · from a complaint · F-0790 |
| Mar 22, 2024 | D · Potential for more than minimal harm, isolated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint · F-0656 |
| Jul 28, 2023 | F · Potential for more than minimal harm, widespread | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Jul 28, 2023 | D · Potential for more than minimal harm, isolated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · F-0558 |
| Jul 28, 2023 | D · Potential for more than minimal harm, isolated | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. · F-0636 |
| Jul 28, 2023 | D · Potential for more than minimal harm, isolated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · F-0657 |
| Jul 28, 2023 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689 |
| Jul 28, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · F-0695 |
| Jul 28, 2023 | D · Potential for more than minimal harm, isolated | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. · F-0712 |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (8 → 8).
All citationsSerious citations (G–L)
2023
All citations: 7
Serious citations (G–L): 0
2024
All citations: 10
Serious citations (G–L): 0
2025
All citations: 8
Serious citations (G–L): 0
2026
All citations: 7
Serious citations (G–L): 0
All bars start at zero. Exact values and supporting details remain below.
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 0 | F |
| 2024 | 10 | 0 | E |
| 2025 | 8 | 0 | E |
| 2026 | 7 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
Nurse staffing (from payroll records, adjusted for how much care residents need)
What these staffing numbers mean →
This facilityTexas averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: 3.20
Texas average: 3.46
U.S. average: 3.95
Registered Nurse hours
This facility: 0.37
Texas average: 0.44
U.S. average: 0.69
Weekend total nurse staffing
This facility: 2.80
Texas average: 3.04
U.S. average: 3.50
All bars start at zero. Exact values and supporting details remain below.
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.20 | 3.46 | 3.95 | bottom 39% in Texas; bottom 21% in the U.S. |
| Registered Nurse hours | 0.37 | 0.44 | 0.69 | bottom 46% in Texas; bottom 18% in the U.S. |
| Weekend total nurse staffing | 2.80 | 3.04 | 3.50 | bottom 39% in Texas; bottom 21% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.50 | 0.34 | 0.48 | top 13% in Texas; top 32% in the U.S. |
| Total nursing staff turnover (%) | 46.2 | 55.3 | 45.8 | top 36% in Texas; bottom 47% in the U.S. |
| RN turnover (%) | 33.3 | 54.6 | 42.9 | top 20% in Texas; top 33% in the U.S. |
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.62, RN 0.42, weekend 3.17.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.62 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 2/5.
Quality measures: assessments & claims
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Costs & payment
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Legend Oaks Healthcare and Rehabilitation Center -. CMS inspection and staffing records do not tell us what this home will charge you.
Calculate a stay from a quote you receive
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Before you compare prices
- Request the room type, effective date and itemized daily rate in writing.
- Ask about therapy, medicines, supplies, care-level charges, deposits, refunds and annual increases.
- Confirm insurance or Medicaid eligibility and bed availability directly; certification alone does not guarantee either.
Understand who pays for care · How we handle price evidence · Report an incorrect price
Who owns this facility
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
For profit - Individual
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Alexander, Alma | Individual | Corporate Officer | NOT APPLICABLE | 05/27/2020 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2017 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2016 |
| Hutchins Healthcare INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Hutchins Healthcare INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/24/2025 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Martinez, Fernando | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/16/2017 |
| Martinez, Fernando | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/16/2017 |
| Martinez, Fernando | Individual | ADP of the SNF | NOT APPLICABLE | 08/16/2017 |
| 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 |
| Yamsani, Pradeep | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/30/2019 |
| Yamsani, Pradeep | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/30/2019 |
| Yamsani, Pradeep | Individual | ADP of the SNF | NOT APPLICABLE | 05/30/2019 |
All 14 owning or managing parties CMS has on file are shown — none excluded.
Other facilities in the same chain
CMS lists this facility under the chain The Ensign Group — 342 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
- Legend Oaks Healthcare and Rehabilitation Center - — Houston, TX · overall 2/5
- Legend Oaks Healthcare and Rehabilitation Center G — Gladewater, TX · overall 2/5
- Legend Oaks Healthcare and Rehabilitation Garland — Garland, TX · overall 3/5
- Legend Oaks Healthcare and Rehabilitation-Kyle — Kyle, TX · overall 3/5
- Mason Creek Transitional Care of Katy — Katy, TX · overall 3/5
- McAllen Transitional Care Center — McAllen, TX · overall 4/5
- McKinney Healthcare and Rehabilitation Center — McKinney, TX · overall 4/5
- Mesa Springs Healthcare Center — Abilene, TX · overall 2/5
Listed by state, then facility name — not a ranking. Showing 8 of the 341 others, continuing from this facility's own place in that list.
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "If I ask for a copy of my family member's records, how quickly will I get them and what does it cost?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you handle residents who need modified food textures, and how do you make those meals appetizing?"
- "Where do you post your latest state inspection results and the ombudsman's contact information?"
- "How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
Also worth asking anywhere
- "Your weekend nurse staffing is reported below the Texas midpoint — how does the weekend schedule differ from a weekday?"
- "Can I see the plan of correction for the findings in your most recent state inspection?"
- "CMS reports 46% total nursing staff turnover here — who on the care team has been with you longest?"
- "The ownership record on file lists 14 owning or managing parties — who makes the decisions about staffing levels?"
- "Can I visit again unannounced, at a mealtime or on a weekend?"
Nearby facilities (12 closest of 63 within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avir at San Antonio | 0.8 mi | San Antonio, TX | ★☆☆☆☆ | 2/5 | |
| Hunters Pond Rehabilitation and Healthcare | 1.8 mi | San Antonio, TX | ★★★☆☆ | 2/5 | |
| San Jose Nursing Center | 1.9 mi | San Antonio, TX | ★★★☆☆ | 3/5 | |
| Windsor Mission Oaks | 3.8 mi | San Antonio, TX | ★★★☆☆ | 3/5 | |
| San Antonio West Nursing and Rehabilitation | 4.3 mi | San Antonio, TX | ★☆☆☆☆ | 1/5 | |
| Harbor Valley Health and Rehabilitation | 4.7 mi | San Antonio, TX | ★★☆☆☆ | 2/5 | abuse |
| The Rio at Mission Trails | 5.1 mi | San Antonio, TX | ★☆☆☆☆ | 2/5 | |
| Highland Nursing Center | 6.4 mi | San Antonio, TX | ★☆☆☆☆ | 2/5 | |
| The Mission at Blue Skies of Texas East | 6.9 mi | San Antonio, TX | ★★★★★ | 4/5 | |
| Memorial Medical Nursing and Rehabilitation | 7.0 mi | San Antonio, TX | ★☆☆☆☆ | 1/5 | |
| River City Care Center | 7.0 mi | San Antonio, TX | ★☆☆☆☆ | 2/5 | abuse |
| The Sarah Roberts French Home | 7.2 mi | San Antonio, TX | ★★☆☆☆ | 3/5 |
Compare this facility with the 3 closest →
Other facilities in the same county
CMS records place this facility in Bexar, TX — 62 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
- Meridian Care Monte Vista — San Antonio, TX · overall 1/5
- Mesa Vista Inn Health Center — San Antonio, TX · overall 1/5
- Morningside Manor — San Antonio, TX · overall 4/5
- Mystic Park Nursing and Rehabilitation Center — San Antonio, TX · overall 3/5
- Normandy Terrace Nursing & Rehabilitation Center — San Antonio, TX · overall 1/5abuse
- Northeast Rehabilitation and Healthcare Center — San Antonio, TX · overall 1/5
- Oak Park Nursing and Rehabilitation Center — San Antonio, TX · overall 2/5
Listed by facility name — not a ranking. Homes already in the table above are not repeated here.
Facility data as of CMS processing date 2026-08-01. CCN 676113.