Legend Oaks Healthcare and Rehabilitation - West S
222 Bertetti Dr, San Antonio, TX 78227 · Bexar County · 124 certified beds · avg 109 residents/day · certified since May 31, 2012
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
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.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Apr 12, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 15, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (20)
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 |
|---|---|---|
| Jun 12, 2026 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jun 12, 2026 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Apr 23, 2026 | 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. · from a complaint |
| Apr 23, 2026 | 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. · from a complaint |
| Jan 29, 2026 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jan 29, 2026 | E · Potential for harm, repeated | 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. |
| Jan 29, 2026 | 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. |
| Jan 29, 2026 | E · Potential for harm, repeated | 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. |
| Jan 29, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Jan 29, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Dec 9, 2025 | 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. · from a complaint |
| Oct 31, 2024 | F · Potential for harm, facility-wide | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Oct 31, 2024 | 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. |
| Apr 12, 2024 | ▲ J · Immediate jeopardy, 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 |
| Apr 12, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Sep 15, 2023 | D · Potential for harm, one-off | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Sep 15, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Sep 15, 2023 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Sep 15, 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. |
| Sep 15, 2023 | 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. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | D |
| 2024 | 4 | 1 | J ▲ |
| 2025 | 1 | 0 | D |
| 2026 | 10 | 0 | E |
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)
1 fine totaling $8,632.
| Date | Type | Amount / length |
|---|---|---|
| Apr 12, 2024 | Fine | $8,632 |
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) | 3.29 | 3.46 | 3.95 | bottom 48% in Texas; bottom 26% in the U.S. |
| Registered Nurse hours | 0.48 | 0.44 | 0.69 | top 29% in Texas; bottom 35% in the U.S. |
| Weekend total nurse staffing | 2.89 | 3.04 | 3.50 | bottom 48% in Texas; bottom 25% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.42 | 0.34 | 0.48 | top 23% in Texas; top 46% in the U.S. |
| Total nursing staff turnover (%) | 20.7 | 55.3 | 45.8 | top 1% in Texas; top 3% in the U.S. |
| RN turnover (%) | 18.2 | 54.6 | 42.9 | top 6% in Texas; top 12% 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 3.64, RN 0.53, weekend 3.20. Staffing rating: 3/5.
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: 4/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Dewitt Medical District | Organization | 5% or Greater Indirect Ownership Interest | 100% | 04/01/2017 |
| Alexander, Alma | Individual | Corporate Officer | NOT APPLICABLE | 05/27/2020 |
| Bertetti Healthcare, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Bertetti Healthcare, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 10/24/2025 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2017 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2016 |
| Gray, Robert | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/15/2017 |
| Gray, Robert | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/15/2017 |
| Gray, Robert | Individual | ADP of the SNF | NOT APPLICABLE | 12/15/2017 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Mansoor, Saad | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/12/2023 |
| Mansoor, Saad | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/12/2023 |
| 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 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "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 |
|---|---|---|---|---|---|
| The Mission at Blue Skies of Texas East | 1.2 mi | San Antonio, TX | ★★★★★ | 4/5 | |
| Lakeside Nursing and Rehabilitation Center | 2.3 mi | San Antonio, TX | ★★★★★ | 4/5 | |
| Westover Hills Rehabilitation and Healthcare | 3.7 mi | San Antonio, TX | ★★★★☆ | 3/5 | |
| Windemere at Westover Hills | 4.2 mi | San Antonio, TX | ★★☆☆☆ | 3/5 | |
| Harbor Valley Health and Rehabilitation | 4.4 mi | San Antonio, TX | ★★☆☆☆ | 2/5 | abuse |
| Las Colinas of Westover | 4.9 mi | San Antonio, TX | ★★☆☆☆ | 2/5 | |
| Silver Creek Nursing and Rehabilitation | 6.0 mi | San Antonio, TX | ★★★☆☆ | 4/5 | |
| San Antonio West Nursing and Rehabilitation | 6.3 mi | San Antonio, TX | ★☆☆☆☆ | 1/5 | |
| Inspiration Hills Rehabilitation Center | 6.8 mi | San Antonio, TX | ★★★☆☆ | 3/5 | |
| Avir at San Antonio | 7.0 mi | San Antonio, TX | ★☆☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
All facilities in San Antonio →
Facility data as of CMS processing date 2026-08-01. CCN 676312.