Legend Oaks Healthcare And Rehabilitation - West S
San Antonio, Bexar County, Texas · CCN 676312 · For-profit (Corporation) · part of The Ensign Group (342 facilities, chain average 3.2 stars)
CMS rates Legend Oaks Healthcare And Rehabilitation - West S 3 of 5 overall as of August 2026. 124 certified beds, 109 residents a day on average. 20 citations on record from the current inspection cycles, 1 at immediate jeopardy; 1 fine totalling $8,632.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★☆☆ 3 of 5 |
|---|---|
| Health inspections | ★★★☆☆ 3 of 5 |
| Staffing | ★★★☆☆ 3 of 5 |
| Quality measures | ★★★★☆ 4 of 5 |
| Quality: long-stay / short-stay | 4 / 5 of 5 |
Staffing
| Total nurse staffing | 3.6379 hours per resident per day |
|---|---|
| Registered nurses | 0.5316 hours per resident per day |
| Weekend total | 3.2005 hours per resident per day |
| Nursing staff turnover | 20.7% (registered nurses 18.2%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-06-12 complaint survey |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-07-03 |
| 2026-06-12 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-07-03 |
| 2026-04-23 complaint survey |
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 Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-14 |
| 2026-04-23 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-14 |
| 2026-01-29 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-18 |
| 2026-01-29 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-18 |
| 2026-01-29 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · tag F0628 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-18 |
| 2025-12-09 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-12-10 |
| 2024-10-31 | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · tag F0576 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 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. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-22 |
| 2024-04-12 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-04-15 |
| 2024-04-12 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-15 |
| 2023-09-15 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · tag F0638 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-12 |
| 2023-09-15 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · tag F0644 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-12 |
| 2023-09-15 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-12 |
| 2023-09-15 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-12 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-04-12 | Fine | $8,632 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Dewitt Medical District Organization | 5% or greater indirect ownership interest | 100% | 2017-04-01 |
| Bertetti Healthcare, Inc. Organization | adp of the snf | — | 2025-10-24 |
| Ensign Services Inc. Organization | adp of the snf | — | 2016-05-01 |
| National Health Investors, Inc. Organization | adp of the snf | — | 2017-04-01 |
| Texas Nhi Investors, LLC Organization | adp of the snf | — | 2017-04-01 |
| Bertetti Healthcare, Inc. Organization | operational/managerial control | — | 2017-04-01 |
| Gray, Robert Individual | adp of the snf | — | 2017-12-15 |
| Mansoor, Saad Individual | adp of the snf | — | 2023-09-12 |
| Alexander, Alma Individual | corporate officer | — | 2020-05-27 |
| Burnam, Soon Individual | corporate officer | — | 2017-04-01 |
| Keetch, Chad Individual | corporate officer | — | 2011-03-01 |
| Gray, Robert Individual | managing control - governing body | — | 2017-12-15 |
| Mansoor, Saad Individual | managing control - governing body | — | 2023-09-12 |
| Gray, Robert Individual | operational/managerial control | — | 2017-12-15 |
| Mansoor, Saad Individual | operational/managerial control | — | 2023-09-12 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Bexar County.