SeniorHomeViolations
B
75/100

Legend Oaks Healthcare and Rehabilitation - West S Inspection Report, Violations & Safety Grade (San Antonio, Texas)

222 Bertetti Dr, San Antonio, Texas 78227

Phone: 2106731700

CMS Overall:3/5

Overview & Bed Count

Certified Beds
124
Avg Residents/Day
101.5
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Bexar
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall3/5
Health3/5
Staffing3/5
Quality4/5

Nurse Staffing Check

MetricThis FacilityTexas AvgDifference
RN Hours per Resident per Day0.480.44+0.04
Total Nurse Hours per Resident per Day3.553.42+0.14
CMS Staffing Rating3/51.9/5-
Nursing Staff Turnover25.9%50.8%-

Health Citation History

20 health citations on record

DateCategoryDescriptionSeverity
2026-06-12Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.E – Moderate Harm Potential
2026-06-12Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.E – Moderate Harm Potential
2026-04-23Quality of Life and Care DeficienciesProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.D – Moderate Harm Potential
2026-04-23Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2026-01-29Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.E – Moderate Harm Potential
2026-01-29Pharmacy Service DeficienciesEnsure 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 – Moderate Harm Potential
2026-01-29Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2026-01-29Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2026-01-29Resident Rights DeficienciesProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.D – Moderate Harm Potential
2026-01-29Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D – Moderate Harm Potential
2025-12-09Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2024-10-31Resident Rights DeficienciesEnsure residents have reasonable access to and privacy in their use of communication methods.F – Moderate Harm Potential
2024-10-31Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2024-04-12Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.J – Immediate Jeopardy
2024-04-12Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2023-09-15Resident Assessment and Care Planning DeficienciesAssure that each resident’s assessment is updated at least once every 3 months.D – Moderate Harm Potential
2023-09-15Resident Assessment and Care Planning DeficienciesCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.D – Moderate Harm Potential
2023-09-15Resident Assessment and Care Planning DeficienciesPASARR screening for Mental disorders or Intellectual DisabilitiesD – Moderate Harm Potential
2023-09-15Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2023-09-15Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.D – Moderate Harm Potential

Fire Safety Citation History

3 fire safety citations on record

DateCategoryDescriptionSeverity
2026-01-29Miscellaneous DeficienciesHave posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.E – Moderate Harm Potential
2026-01-29Egress DeficienciesKeep aisles, corridors, and exits free of obstruction in case of emergency.D – Moderate Harm Potential
2024-10-31Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential

Total Penalties & Fines

$8,632
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
DateTypeFine AmountPayment Denial
2024-04-12Fine$8,632-

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