Legend Oaks Healthcare and Rehabilitation - West S

Nursing home in San Antonio, TX

Medicare & Medicaid certified3★ overall (CMS)

Call (210) 673-1700 Send a message Map ↗

Public-record details

Address: 222 Bertetti Dr, San Antonio, TX 78227
Phone: (210) 673-1700
Listed under: For-profit
Medicare CCN: 676312
Overall star rating: 3 of 5 ★★★☆☆
Health inspection rating: 3 of 5
Staffing rating: 3 of 5
Quality measures rating: 4 of 5
Certified beds: 124
Average residents per day: 109
Ownership: For-profit, corporation
Legal business name: Dewitt Medical District
Chain: The Ensign Group (342 facilities)
Certified for: Medicare and Medicaid
First approved by Medicare/Medicaid: May 31, 2012
Changed ownership in last 12 months: No
Continuing care retirement community: No
Located inside a hospital: No
Resident or family council: Resident council
Sprinklers in all required areas: Yes

CMS certification number 676312. Source: CMS Nursing Home Provider Information, Health Deficiencies and Penalties (record). Data as of 2026-09-30.

Inspection record

Most recent standard health inspection: Jan 29, 2026. CMS lists 20 health citations for this facility across its last three standard inspection cycles and complaint inspections (Sep 15, 2023 to Jun 12, 2026): 7 from complaint inspections, 1 at the “actual harm” level or higher, including 1 at “immediate jeopardy”.

Inspection	Citation	Severity
Jun 12, 2026	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights · complaint inspection	E Potential for more than minimal harm, pattern
Jun 12, 2026	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation · complaint inspection	E Potential for more than minimal harm, pattern
Apr 23, 2026	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care · complaint inspection	D Potential for more than minimal harm, isolated
Apr 23, 2026	Provide and implement an infection prevention and control program. Infection Control · complaint inspection	D Potential for more than minimal harm, isolated
Jan 29, 2026	Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights	D Potential for more than minimal harm, isolated
Jan 29, 2026	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service	D Potential for more than minimal harm, isolated
Jan 29, 2026	Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning	E Potential for more than minimal harm, pattern
Jan 29, 2026	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… Pharmacy Service	E Potential for more than minimal harm, pattern
Jan 29, 2026	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary	E Potential for more than minimal harm, pattern
Jan 29, 2026	Provide and implement an infection prevention and control program. Infection Control	E Potential for more than minimal harm, pattern
Dec 9, 2025	Provide and implement an infection prevention and control program. Infection Control · complaint inspection	D Potential for more than minimal harm, isolated
Oct 31, 2024	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning	D Potential for more than minimal harm, isolated

Showing the 12 most recent of 20. Full inspection reports are on Medicare Care Compare.

Severity letters follow CMS's scope-and-severity grid: A–C potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, J–L immediate jeopardy. Most citations are corrected; a citation is what inspectors found on that date. Source: CMS Health Deficiencies file, processed Aug 1, 2026.

Fines and payment denials

CMS records 1 fine totalling $8,632 in the last three years.

Apr 12, 2024

Fine: $8,632

Source: CMS Penalties file, processed Aug 1, 2026. Amounts are as CMS reports them and may reflect later reductions or appeals.

Staffing

Total nurse staffing per resident per day: 3.64 hours
Registered nurse (RN) time per resident per day: 0.53 hours
Nurse aide time per resident per day: 2.12 hours
Total nurse staffing on weekends: 3.20 hours
Nursing staff turnover (yearly): 21%
RN turnover (yearly): 18%
Administrators who left in the past year: 0

From payroll-based staffing data the facility submits to CMS. Hours are per resident per day.

A citation is what inspectors found on one date; most are corrected within weeks. Look for patterns — the same problem cited in several inspections — and for anything at the G–L level (actual harm or immediate jeopardy). The full inspection narrative (Form CMS-2567) is linked from Medicare Care Compare, and your state long-term care ombudsman can tell you about complaints.

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