Legend Oaks Healthcare and Rehabilitation - West S
222 Bertetti Dr · San Antonio, TX · 78227 · 2106731700
124 certified beds For profit - Corporation Chain: The Ensign Group
- Inspection results have improved across recent cycles.
The composite number cleared 71 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
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
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 3 of 5 Staffing: 2 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.48 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.44 | 0.55–0.75 |
| Weekend hours / resident-day | 3.03 | ≈ weekday level |
| Nursing turnover / year | 28% | median 45% |
| Fines (3-yr window) | 1 · $8,632 |
Inspection citations (18 in the current record)
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Potential for harm · D April 23, 2026 · found via complaint
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 May 14, 2026 · Quality of Life and Care
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Potential for harm · D April 23, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Corrected May 14, 2026 · Infection Control
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Potential for harm · D January 29, 2026
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected February 18, 2026 · Resident Rights
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Potential for harm · E January 29, 2026
Ensure each resident receives an accurate assessment.
Corrected February 18, 2026 · Resident Assessment and Care Planning
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Potential for harm · D January 29, 2026
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected February 18, 2026 · Pharmacy Service
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Potential for harm · E January 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 locked compartments, separately locked, compartments for controlled drugs.
Corrected February 18, 2026 · Pharmacy Service
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Potential for harm · E January 29, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 18, 2026 · Nutrition and Dietary
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Potential for harm · E January 29, 2026
Provide and implement an infection prevention and control program.
Corrected February 18, 2026 · Infection Control
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Potential for harm · D December 9, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected December 10, 2025 · Infection Control
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Potential for harm · F October 31, 2024
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected November 22, 2024 · Resident Rights
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Potential for harm · D October 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.
Corrected November 22, 2024 · Resident Assessment and Care Planning
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Immediate jeopardy · J April 12, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 15, 2024 · Quality of Life and Care
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Potential for harm · D April 12, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected April 15, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 15, 2023
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected October 12, 2023 · Resident Assessment and Care Planning
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Potential for harm · D September 15, 2023
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected October 12, 2023 · Resident Assessment and Care Planning
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Potential for harm · D September 15, 2023
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected October 12, 2023 · Resident Assessment and Care Planning
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Potential for harm · D September 15, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 12, 2023 · Quality of Life and Care
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Potential for harm · D September 15, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 12, 2023 · Nutrition and Dietary
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| April 12, 2024 | Fine | $8,632 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 676312 · certified since May 31, 2012. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.