Nursing homes › Texas › Legend Oaks Healthcare and Rehabilitation - West S
222 Bertetti Dr, San Antonio, TX 78227 · 2106731700 · 124 certified beds
Per CMS filings, this facility is affiliated with The Ensign Group, a group operating 346 facilities in 17 states. Group record: average rating 3.2/5, 33 abuse citation icons, 9 facilities on the Special Focus list, $7,179,329 in federal fines. This facility rates below its group average (3.2/5).
Total nurse staffing: 3.64 (Texas median: 3.27). RN hours: 0.53. Weekend total: 3.20. Nursing staff turnover: 21%.
All-time on record: 18 deficiency citations, including 1 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 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. | D | complaint | corrected 2026-05-14 |
| 2026-04-23 | Provide and implement an infection prevention and control program. | D | complaint | corrected 2026-05-14 |
| 2026-01-29 | Ensure each resident receives an accurate assessment. | E | Health | 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. | E | Health | 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. | E | Health | corrected 2026-02-18 |
| 2026-01-29 | Provide and implement an infection prevention and control program. | E | Health | 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. | D | Health | 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. | D | Health | corrected 2026-02-18 |
| 2025-12-09 | Provide and implement an infection prevention and control program. | D | complaint | corrected 2025-12-10 |
| 2024-10-31 | Ensure residents have reasonable access to and privacy in their use of communication methods. | F | Health | 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. | D | Health | 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. | J | complaint | corrected 2024-04-15 |
| 2024-04-12 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | complaint | corrected 2024-04-15 |
| 2023-09-15 | Assure that each resident’s assessment is updated at least once every 3 months. | D | Health | corrected 2023-10-12 |
| 2023-09-15 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | Health | corrected 2023-10-12 |
| 2023-09-15 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Health | 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. | D | Health | 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. | D | Health | corrected 2023-10-12 |
| Date | Type | Amount |
|---|---|---|
| 2024-04-12 | Fine | $8,632 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| DEWITT MEDICAL DISTRICT | 5% Or Greater Indirect Ownership Interest | Organization | 100% | since 04/01/2017 |
| GRAY, ROBERT | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 12/15/2017 |
| MANSOOR, SAAD | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 09/12/2023 |
| ALEXANDER, ALMA | Corporate Officer | Individual | NOT APPLICABLE | since 05/27/2020 |
| BURNAM, SOON | Corporate Officer | Individual | NOT APPLICABLE | since 04/01/2017 |
| KEETCH, CHAD | Corporate Officer | Individual | NOT APPLICABLE | since 03/01/2011 |
| BERTETTI HEALTHCARE, INC. | Operational/Managerial Control | Organization | NOT APPLICABLE | since 04/01/2017 |
| GRAY, ROBERT | Operational/Managerial Control | Individual | NOT APPLICABLE | since 12/15/2017 |
| MANSOOR, SAAD | Operational/Managerial Control | Individual | NOT APPLICABLE | since 09/12/2023 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 676312. Corrections: data@carerecords.org.