Legend Oaks Healthcare and Rehabilitation Center -
2003 W Hutchins Place · San Antonio, TX · 78224 · 2109270800
126 certified beds For profit - Individual Chain: The Ensign Group
- No federal fines or payment denials in CMS’s 3-year window.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
No red flags in the current CMS record. Genuinely good news — pair it with an in-person tour before deciding.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 5 of 5 Inspections: 4 of 5 Staffing: 2 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.45 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.47 | 0.55–0.75 |
| Weekend hours / resident-day | 3.01 | ≈ weekday level |
| Nursing turnover / year | 40% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (25 in the current record)
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Potential for harm · D December 4, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected December 30, 2025 · Resident Rights
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Potential for harm · D December 4, 2025
Keep residents' personal and medical records private and confidential.
Corrected December 30, 2025 · Resident Rights
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Potential for harm · D December 4, 2025
Ensure each resident receives an accurate assessment.
Corrected December 30, 2025 · Resident Assessment and Care Planning
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Potential for harm · E December 4, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected December 30, 2025 · Quality of Life and Care
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Potential for harm · D December 4, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected December 30, 2025 · Pharmacy Service
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Potential for harm · D December 4, 2025
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 locked compartments, separately locked, compartments for controlled drugs.
Corrected December 30, 2025 · Pharmacy Service
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Potential for harm · D December 4, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 30, 2025 · Nutrition and Dietary
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Potential for harm · D December 4, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected December 30, 2025 · Resident Assessment and Care Planning
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Potential for harm · D September 27, 2024
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected October 20, 2024 · Resident Rights
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Potential for harm · E September 27, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected October 20, 2024 · Resident Assessment and Care Planning
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Potential for harm · D September 27, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected October 20, 2024 · Quality of Life and Care
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Potential for harm · D September 27, 2024
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected October 20, 2024 · Quality of Life and Care
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Potential for harm · E September 27, 2024
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected October 20, 2024 · Quality of Life and Care
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Potential for harm · E September 27, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 20, 2024 · Nutrition and Dietary
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Potential for harm · D September 27, 2024
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected October 20, 2024 · Administration
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Potential for harm · D September 27, 2024
Provide and implement an infection prevention and control program.
Corrected October 20, 2024 · Infection Control
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Potential for harm · D March 22, 2024 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 26, 2024 · Resident Assessment and Care Planning
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Potential for harm · E March 22, 2024 · found via complaint
Provide routine and 24-hour emergency dental care for each resident.
Corrected March 26, 2024 · Quality of Life and Care
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Potential for harm · D July 28, 2023
Reasonably accommodate the needs and preferences of each resident.
Corrected August 16, 2023 · Resident Rights
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Potential for harm · D July 28, 2023
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected August 16, 2023 · Resident Assessment and Care Planning
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Potential for harm · D July 28, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected August 16, 2023 · Resident Assessment and Care Planning
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Potential for harm · D July 28, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 16, 2023 · Quality of Life and Care
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Potential for harm · D July 28, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Corrected August 16, 2023 · Quality of Life and Care
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Potential for harm · D July 28, 2023
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected August 16, 2023 · Nursing and Physician Services
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Potential for harm · F July 28, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected August 16, 2023 · Nutrition and Dietary
Better-scoring options nearby
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 676113 · certified since October 10, 2006. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.