222 Bertetti Dr, San Antonio, TX 78227 (opens Google Maps) · Bexar County · (210) 673-1700· 124 certified beds · avg 109 residents/day · certified since May 31, 2012 · 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★)
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.
▲ Immediate jeopardy, isolated · 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): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Apr 15, 2024 (Deficient, Provider has date of correction)
Showing the latest 3 of 20 inspection findings. Open the full record below to read every finding.
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 F-0550
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 F-0609
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 F-0690
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 |
|---|---|---|
| Jun 12, 2026 | E · Potential for more than minimal harm, pattern | 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 · F-0550 |
| Jun 12, 2026 | E · Potential for more than minimal harm, pattern | 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 · F-0609 |
| Apr 23, 2026 | 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. · from a complaint · F-0690 |
| Apr 23, 2026 | 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. · from a complaint · F-0880 |
| Jan 29, 2026 | E · Potential for more than minimal harm, pattern | 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 |
| Jan 29, 2026 | E · Potential for more than minimal harm, pattern | 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 |
| Jan 29, 2026 | 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 |
| Jan 29, 2026 | E · Potential for more than minimal harm, pattern | 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 |
| Jan 29, 2026 | D · Potential for more than minimal harm, isolated | 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). · F-0628 |
| Jan 29, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755 |
| Dec 9, 2025 | 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. · from a complaint · F-0880 |
| Oct 31, 2024 | F · Potential for more than minimal harm, widespread | 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. · F-0576 |
| Oct 31, 2024 | 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 |
| Apr 12, 2024 | ▲ J · Immediate jeopardy, 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 |
| Apr 12, 2024 | D · Potential for more than minimal harm, isolated | 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 · F-0609 |
| Sep 15, 2023 | D · Potential for more than minimal harm, isolated | 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. · F-0638 |
| Sep 15, 2023 | D · Potential for more than minimal harm, isolated | 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. · F-0644 |
| Sep 15, 2023 | D · Potential for more than minimal harm, isolated | 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. · F-0645 |
| Sep 15, 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 |
| Sep 15, 2023 | 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 |
Citations from standard inspections increased between the last two inspection cycles (2 → 6).
All bars start at zero. Exact values and supporting details remain below.
| 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.
How to file a complaint about care →
1 fine totaling $8,632.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
| Date | Type | Amount / length |
|---|---|---|
| Apr 12, 2024 | Fine | $8,632 |
What these staffing numbers mean →
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) | 3.29 | 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 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 3.64, RN 0.53, weekend 3.20.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.64 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 3/5.
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: 4/5 · short-stay residents: 5/5
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Legend Oaks Healthcare and Rehabilitation - West S. CMS inspection and staffing records do not tell us what this home will charge you.
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.
Understand who pays for care · How we handle price evidence · Report an incorrect price
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 - 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 |
All 15 owning or managing parties CMS has on file are shown — none excluded.
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.
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.
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
| 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 | 4.3 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 | |
| Legend Oaks Healthcare and Rehabilitation Center - | 7.8 mi | San Antonio, TX | ★★★☆☆ | 3/5 | |
| The Sarah Roberts French Home | 7.9 mi | San Antonio, TX | ★★☆☆☆ | 3/5 |
Compare this facility with the 3 closest →
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.
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 676312.
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