Nursing homeActive
Legend Oaks Healthcare and Rehabilitation - West S
222 Bertetti Dr, San Antonio, TX 782272106731700124 certified beds · 109 residentsFor profit - CorporationMedicare and Medicaid
Surveys on file
7
since 2023
Deficiencies
20
● 0● 19● 1
Penalties · 3 yrs
$8,632
1 fine
Last survey
2026-06-12
Complaint
CMS overall
3 / 5
stars as published by CMS
CMS overall 3/5
Health 3
Staffing 3
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Texas Health and Human Services Commission · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-06-12 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2026-04-23 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2026-01-29 | Standard | 060 | CMS-2567 (Care Compare) | — |
| 2025-12-09 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-10-31 | Standard | 020 | CMS-2567 (Care Compare) | — |
| 2024-04-12 | Complaint | 011 | CMS-2567 (Care Compare) | — |
| 2023-09-15 | Standard | 050 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Texas Health and Human Services Commission publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-07-03Record 676312-20260612-F550
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-07-03Record 676312-20260612-F609
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-14Record 676312-20260423-F690
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-14Record 676312-20260423-F880
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-18Record 676312-20260129-F628
F641Ensure each resident receives an accurate assessment.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-18Record 676312-20260129-F641
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-18Record 676312-20260129-F755
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-18Record 676312-20260129-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-18Record 676312-20260129-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-18Record 676312-20260129-F880
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-10Record 676312-20251209-F880
F576Ensure residents have reasonable access to and privacy in their use of communication methods.Scope/severity FStandard
Dignity & rights
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-11-22Record 676312-20241031-F576
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-22Record 676312-20241031-F657
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-04-15Record 676312-20240412-F689
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-15Record 676312-20240412-F609
F638Assure that each resident’s assessment is updated at least once every 3 months.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-12Record 676312-20230915-F638
F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-12Record 676312-20230915-F644
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-12Record 676312-20230915-F645
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-12Record 676312-20230915-F689
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-12Record 676312-20230915-F812
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2024-04-12 | Civil money penalty | $8,632 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.53
Facility
Texas
National
Texas 0.43 · National 0.69
Total nurse hours per resident day3.64
Facility
Texas
National
Texas 3.39 · National 3.86
Weekend total nurse hours3.20
Facility
Texas
National
Texas 2.98 · National 3.42
Total nursing staff turnover21%
Facility
Texas
National
Texas 55% · National 46%
Registered nurse turnover18%
Facility
Texas
National
Texas 55% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Texas | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 1.6% | 3.8% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 0.0% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 3.6% | 9.6% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 3.1% | 0.8% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 12.9% | 15.8% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 3.9% | 3.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 11.9% | 18.0% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Dewitt Medical District Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | — | — |
| 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 | — | — |
| Alexander, Alma Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Bertetti Healthcare, Inc. Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Burnam, Soon Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Ensign Services Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Gray, Robert Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Gray, Robert Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Keetch, Chad Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Mansoor, Saad Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Mansoor, Saad Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| National Health Investors, Inc. Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Texas Nhi Investors, LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
The Ensign Group — 342 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Texas.
No county cost figures on file for Bexar.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| The Mission At Blue Skies Of Texas East San Antonio | 1.2 mi | 2025-08-08 | 0202 |
| Lakeside Nursing And Rehabilitation Center San Antonio | 2.3 mi | 2026-06-05 | 0163 |
| Westover Hills Rehabilitation And Healthcare San Antonio | 3.7 mi | 2026-06-12 | 0272 |
| Windemere At Westover Hills San Antonio | 4.2 mi | 2025-12-19 | 0152 |
| Harbor Valley Health and Rehabilitation San Antonio | 4.4 mi | 2026-01-21 | 0332 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |