Legend Oaks Healthcare and Rehabilitation Center -

Name: Legend Oaks Healthcare and Rehabilitation Center -
Address: 2003 W HUTCHINS PLACE, San Antonio, TX, 78224, US
Telephone: 2109270800

2003 W Hutchins Place, San Antonio, TX 78224 · Bexar County · 126 certified beds · avg 108 residents/day · certified since Oct 10, 2006

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.20

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5

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 self-reported quality measures.

All citations in the current public record (32)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
May 15, 2026	D · Potential for harm, one-off	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
May 15, 2026	D · Potential for harm, one-off	The facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint
May 15, 2026	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential. · from a complaint
May 15, 2026	D · Potential for harm, one-off	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
May 15, 2026	D · Potential for harm, one-off	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
May 15, 2026	B · Minimal risk, repeated	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
May 15, 2026	B · Minimal risk, repeated	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
Dec 4, 2025	E · Potential for harm, repeated	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.
Dec 4, 2025	D · Potential for harm, one-off	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.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Dec 4, 2025	D · Potential for harm, one-off	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.
Dec 4, 2025	D · Potential for harm, one-off	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.
Dec 4, 2025	D · Potential for harm, one-off	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.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Sep 27, 2024	E · Potential for harm, repeated	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.
Sep 27, 2024	E · Potential for harm, repeated	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.
Sep 27, 2024	E · Potential for harm, repeated	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.
Sep 27, 2024	D · Potential for harm, one-off	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.
Sep 27, 2024	D · Potential for harm, one-off	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.
Sep 27, 2024	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Sep 27, 2024	D · Potential for harm, one-off	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.
Sep 27, 2024	D · Potential for harm, one-off	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.
Mar 22, 2024	E · Potential for harm, repeated	The facility did not provide routine dental care and 24-hour emergency dental care for residents. · from a complaint
Mar 22, 2024	D · Potential for harm, one-off	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
Jul 28, 2023	F · Potential for harm, facility-wide	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.
Jul 28, 2023	D · Potential for harm, one-off	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.
Jul 28, 2023	D · Potential for harm, one-off	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.
Jul 28, 2023	D · Potential for harm, one-off	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.
Jul 28, 2023	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jul 28, 2023	D · Potential for harm, one-off	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.
Jul 28, 2023	D · Potential for harm, one-off	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.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (8 → 8).

Year	Citations	Worst severity that year
2023	7	F
2024	10	E
2025	8	E
2026	7	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)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

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, 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. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5

Who owns this facility

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

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?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (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
River City Care Center	7.0 mi	San Antonio, TX	★☆☆☆☆	2/5	abuse

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 676113.

The Care File

Visit checklist — Legend Oaks Healthcare and Rehabilitation Center -

2003 W Hutchins Place, San Antonio, TX 78224 · 2109270800

Health inspection rating 3/5 · CMS overall 3/5· Fines (3y): $0

Questions for the administrator:

☐ "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?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 676113 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)