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Nursing homeFAID #14672

Legend Oaks Healthcare and Rehabilitation - West San Antonio

222 BERTETTI DR, SAN ANTONIO, TX, 78227
(210) 673-1700
ensignservices.net
124 licensed beds
★★★★★3/5CMS Five-Star overall3/5 health inspections3/5 staffing4/5 quality measuresSource: CMS Care Compare

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Photo of Legend Oaks Healthcare and Rehabilitation - West San Antonio
Photo via Google · Legend Oaks Healthcare and Rehabilitation - West San Antonio

Public record summary

What we can show you for free.
Bed capacity
124
CMS facility ID
676312
Care type
Nursing home
County
Bexar
Facility name
Legend Oaks Healthcare and Rehabilitation - West San Antonio
Street address
222 BERTETTI DR
City / state / ZIP
San Antonio, TX 78227
Phone
(210) 673-1700
Website
ensignservices.net

About this facility — Legend Oaks Healthcare and Rehabilitation - West San Antonio

Legend Oaks Healthcare and Rehabilitation - West San Antonio is a Medicare/Medicaid-certified skilled nursing facility in San Antonio, Texas. It is licensed for 124 beds — close to the median for skilled nursing facilities in Texas (120 beds).

It is one of 341 senior care facilities in San Antonio and 1,178 skilled nursing facilities across Texas. Families comparing options should weigh inspection history, ownership record, and litigation — not just the tour — before deciding.

Federal inspectors have cited Legend Oaks Healthcare and Rehabilitation - West San Antonio 23 times across 11 inspections in the last three years, including 2 food-safety citations, and CMS has imposed $8,632 in fines. Every citation is listed, dated, and graded in the inspection record below.

This listing draws on federal CMS Nursing Home Compare records, and was last updated on August 31, 2026. Background reports are compiled from primary sources — state inspection files, federal CMS data, corporate registrations, and court records — at the time of order.

Facility background

What the public record shows.

Ownership & operator

Parent company
The Ensign Group
Ownership type
For profit - Corporation

Registered owners & officers

Dewitt Medical District
Indirect owner — 100% stake — since 2017
Alexander, Alma
Officer — since 2020
Bertetti Healthcare, Inc.
Operational control · Additional disclosable party — since 2017
Burnam, Soon
Officer — since 2017
Ensign Services Inc
Additional disclosable party — since 2016
Gray, Robert
Governing body · Operational control · Additional disclosable party — since 2017
Keetch, Chad
Officer — since 2011
Mansoor, Saad
Governing body · Operational control · Additional disclosable party — since 2023
National Health Investors, Inc.
Additional disclosable party — since 2017
Texas Nhi Investors, Llc
Additional disclosable party — since 2017

Regulatory standing

Federal court records
11 naming its parent company — view the cases (a listed case is not a finding of wrongdoing)
Licensed / certified since
2012-05-31
CMS overall rating
3 of 5 stars
Health deficiencies
11 at the last standard inspection
Federal fines
$8,632 total
Last standard inspection
2026-01-29
Nurse staffing
3.6 hours per resident per day

Cost & payer profile (FY2023 cost report)

Average billed charges
$381 per day (≈ $11,580/month). Private-pay prices typically track billed charges; Medicare and Medicaid pay set rates.
Payer mix (resident days)
50% Medicaid · 5% Medicare · 45% private/other
Occupancy
85% (fiscal year 2023)
Vs. state median
38% above the TX median of $277/day — full state cost breakdown

Services & coverage

Licensed beds
124
Medicare
Accepted
Medicaid
Accepted
Wheelchair accessible
entrance and parking
Visiting hours
Monday: 7:00 AM – 8:00 PM · Tuesday: 7:00 AM – 8:00 PM · Wednesday: 7:00 AM – 8:00 PM · Thursday: 7:00 AM – 8:00 PM · Friday: 7:00 AM – 8:00 PM · Saturday: Closed · Sunday: Closed
Compiled from CMS Nursing Home Compare; owners/officers from the CMS Ownership dataset; cost & occupancy from the facility's own CMS cost report; hours/accessibility via Google · last verified 2026-08-31. Facilities can submit a correction.

Inspection record

Every citation, dated and graded.

Kitchen & food safety

Federal surveyors inspect the kitchen at every standard visit. This facility has 2 food-safety citations on its three-year record — flagged below among the inspections.
2026-06-12Health inspectionComplaint-triggered2 citations
F-0550
E · No harm foundFrom a complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-07-03
F-0609
E · No harm foundFrom a complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-07-03
2026-04-23Health inspectionComplaint-triggered2 citations
F-0690
D · No harm foundFrom a complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-05-14
F-0880
D · No harm foundFrom a complaint
Provide and implement an infection prevention and control program.
Corrected 2026-05-14
7 earlier / fire-safety inspections (19 citations)
2026-01-29Health inspection6 citations
F-0628
D · No harm found
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-02-18
F-0641
E · No harm found
Ensure each resident receives an accurate assessment.
Corrected 2026-02-18
F-0755
D · No harm found
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-02-18
F-0761
E · No harm found
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.
Corrected 2026-02-18
F-0812
E · No harm foundFood safety
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-18
F-0880
E · No harm found
Provide and implement an infection prevention and control program.
Corrected 2026-02-18
2025-12-09Health inspectionComplaint-triggered1 citation
F-0880
D · No harm foundFrom a complaint
Provide and implement an infection prevention and control program.
Corrected 2025-12-10
2024-10-31Health inspection2 citations
F-0576
F · No harm found
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-11-22
F-0657
D · No harm found
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-22
2024-04-12Health inspectionComplaint-triggered2 citations
F-0609
D · No harm foundFrom a complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-15
F-0689
J · Immediate jeopardyFrom a complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-15
2023-09-15Health inspection5 citations
F-0638
D · No harm found
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-10-12
F-0644
D · No harm found
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-10-12
F-0645
D · No harm found
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-10-12
F-0689
D · No harm found
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-12
F-0812
D · No harm foundFood safety
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-12
2026-01-29Fire-safety inspection2 citations
K-0211
D · No harm found
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-02-18
K-0741
E · No harm found
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2026-02-18
2024-10-31Fire-safety inspection1 citation
K-0372
E · No harm found
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-22

Federal penalties

2024-04-12Fine$8,632
Citations and penalties from the CMS Provider Data Catalog (three-year survey window, refreshed monthly). Severity codes follow the federal scope/severity grid; “Immediate jeopardy” is the most serious grade CMS issues. CCN 676312.

Visitor reviews

What people say on Google.
4.3261 ratings on Google
★★★★Sharon Wilson · 2026-07-06 · via Google

“Everyone has been really nice and helpful. My mom has been here a few times. They are attentive and kind. The nurses and therapists are always so helpful and friendly. I feel comfortable with my mom here. They never treat her like she is a bother.”

★★Rodney Smith · 2026-07-20 · via Google

“it's like most other businesses....some good staff; some not so good. It would be nice if the staff would speak better english. It also would be nice if some members were out and out fired. Those definitely are not people friendly. And some are not timely in their response when you call for help. YOU ARE NOT THE ONLY ONE IN HERE was one response. This nurse was definitely one to be fired. S…”

★★★★★JOSE A. GARCIA · 2026-03-21 · via Google

“My experience at Legend Oaks Healthcare and Rehabilitation was extremely great!!! From the moment you walk in they make you feel welcomed and at home!!! The employees are very nice, friendly, and very courteous!!! The employee who was up at the front desk even went out of her way to open the door for me and for another family member that was visiting the facility with me that day!!! The facility i…”

Ratings and reviews are from Google and reflect visitor opinions, not our verification. See all reviews on Google

Inside your report

What unlocks when you order.

Ownership & corporate history

Primary tier
Prior operators & transfers
Corporate network & affiliates
,
Owners' other facilities
· · 2 more

Inspection citations — last 5 years

Locked
The 23 citations above are shown free. The report takes each one and explains it in plain English — what the tag requires, how serious the scope/severity grade really is, whether it recurred across surveys — plus the five-year pattern a single inspection can't show.

Civil & criminal lawsuits

Advanced tier only
Active civil suits
#
Federal dockets
CDC infection data
Unlock the full file
Citations, owner history, lawsuits — decoded into one PDF.
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Original records

Sources we pull for this facility.
Source
CMS Nursing Home Compare
data.cms.gov Provider Data Catalog
Last verified 2026-08-31
Source
Google Business Profile
Photos, reviews & hours
Displayed with attribution · refreshed on re-run
Source
Secretary of State filings
Entity & officer search
Pulled when a report is ordered
Source
PACER federal dockets
pacer.uscourts.gov
Pulled when a report is ordered