Legend Oaks Healthcare and Rehabilitation - West S

Nursing Home · San Antonio, TX

CMS overall rating 3/5 For profit - Corporation

CMS certification number676312

Contact & location

222 Bertetti Dr
San Antonio, TX 78227
Bexar County
Phone
(210) 673-1700
ZIP code
78227 – all care providers

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Facility details

Certified beds
124
Residents per day
108.8 (88% occupied)
Ownership
For profit - Corporation
Legal name
Dewitt Medical District
Chain
The Ensign Group (342 facilities, avg 3.2★)
Medicare certified since
May 31, 2012
Participates in
Medicare and Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 3/5
State avg 2.6
Health inspections★★★★★ 3/5
State avg 2.8
Staffing★★★★★ 3/5
State avg 1.9
Quality measures★★★★★ 4/5
State avg 3.7
Long-stay quality★★★★★ 4/5
Short-stay quality★★★★★ 5/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
3.64 (state 3.39 · U.S. 3.86)
Registered nurses (RN)
0.53 (state 0.43 · U.S. 0.69)
Licensed practical nurses
0.99 (state 0.95 · U.S. 0.86)
Nurse aides
2.12 (state 2.00 · U.S. 2.32)
Weekend total
3.20 (state 2.98 · U.S. 3.42)
Nursing staff turnover
20.7 (state 55.3 · U.S. 45.8)%
RN turnover
18.2 (state 54.6 · U.S. 42.9)%
Administrators who left
0 in the last year

Inspections

Last standard inspection
January 29, 2026
Health deficiencies (last cycle)
11.0 (state 9.3 · U.S. 9.3)
From complaints
5
Citations on record (3 years)
20 health · 3 fire safety · includes immediate jeopardy
DateCitationSeverityStatus
2026-06-12 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-07-03
2026-06-12 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-07-03
2026-04-23 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F0690 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-05-14
2026-04-23 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-05-14
2026-01-29 Ensure each resident receives an accurate assessment.
F0641 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-02-18
2026-01-29 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.
F0761 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-02-18
2026-01-29 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-02-18
2026-01-29 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-02-18
2026-01-29 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
F0628 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-02-18
2026-01-29 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-02-18
2025-12-09 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-10
2024-10-31 Ensure residents have reasonable access to and privacy in their use of communication methods.
F0576 · Resident Rights Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2024-11-22
2024-10-31 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F0657 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-11-22
2024-04-12 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 J
Immediate jeopardy to resident health or safety		 Corrected 2024-04-15
2024-04-12 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-15
2023-09-15 Assure that each resident’s assessment is updated at least once every 3 months.
F0638 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-10-12
2023-09-15 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F0644 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-10-12
2023-09-15 PASARR screening for Mental disorders or Intellectual Disabilities
F0645 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-10-12
2023-09-15 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-10-12
2023-09-15 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-10-12

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

1 penalty in the last three years, including $8,632 in fines.

DateTypeAmount
2024-04-12Fine$8,632

Ownership & management

NameRoleSince
Dewitt Medical District (organization)5%+ Indirect Ownership Interest · 100%
Bertetti Healthcare, INC. (organization)Administrator · NOT APPLICABLE
Ensign Services INC (organization)Administrator · NOT APPLICABLE
Gray, Robert (individual)Administrator · NOT APPLICABLE
Mansoor, Saad (individual)Administrator · NOT APPLICABLE
National Health Investors, INC. (organization)Administrator · NOT APPLICABLE
Texas Nhi Investors, LLC (organization)Administrator · NOT APPLICABLE
Alexander, Alma (individual)Corporate Officer · NOT APPLICABLE
Burnam, Soon (individual)Corporate Officer · NOT APPLICABLE
Keetch, Chad (individual)Corporate Officer · NOT APPLICABLE
Gray, Robert (individual)Managing Control - Governing Body · NOT APPLICABLE
Mansoor, Saad (individual)Managing Control - Governing Body · NOT APPLICABLE
Bertetti Healthcare, INC. (organization)Operational/managerial Control · NOT APPLICABLE
Gray, Robert (individual)Operational/managerial Control · NOT APPLICABLE
Mansoor, Saad (individual)Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of Legend Oaks Healthcare and Rehabilitation - West S?

Legend Oaks Healthcare and Rehabilitation - West S has a 3-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 2.6-star average in Texas.

How many beds does Legend Oaks Healthcare and Rehabilitation - West S have?

It has 124 certified beds and cares for about 109 residents per day.

Has Legend Oaks Healthcare and Rehabilitation - West S been fined?

Yes. CMS lists 1 penalty totaling $8,632 in the last three years.

Who owns Legend Oaks Healthcare and Rehabilitation - West S?

It is part of The Ensign Group and is classified as for profit - corporation. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Legend Oaks Healthcare and Rehabilitation - West S?

(210) 673-1700. The facility is located at 222 Bertetti Dr, San Antonio, TX 78227.

Other nursing homes in San Antonio

Compare all nursing homes in San Antonio, TX →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.