Facility Watch Inspection records for every certified US nursing home

Legend Oaks Healthcare and Rehabilitation - West S

222 Bertetti Dr
San Antonio, TX 78227
(210) 673-1700

CCN
676312
Certified beds
124
Ownership
For profit - Corporation
Chain
THE Ensign Group

Nurse staffing

3.24
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.41 hours per resident per day

Nursing staff turnover: 28% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected April 23, 2026

2 citations · from a complaint investigation · Health
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected May 14, 2026
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected May 14, 2026

Inspected January 29, 2026

6 citations · Health
D
F0628 No actual harm with potential for more than minimal harm · Isolated

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Deficient, Provider has date of correction · corrected February 18, 2026
D
F0755 No actual harm with potential for more than minimal harm · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected February 18, 2026
E
F0641 No actual harm with potential for more than minimal harm · Pattern

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected February 18, 2026
E
F0761 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected February 18, 2026
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected February 18, 2026
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected February 18, 2026

Inspected December 9, 2025

1 citation · from a complaint investigation · Health
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected December 10, 2025

Inspected October 31, 2024

2 citations · Health
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected November 22, 2024
F
F0576 No actual harm with potential for more than minimal harm · Widespread

Ensure residents have reasonable access to and privacy in their use of communication methods.

Deficient, Provider has date of correction · corrected November 22, 2024

Inspected April 12, 2024

2 citations · from a complaint investigation · Health
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected April 15, 2024
J
F0689 Immediate jeopardy to resident health or safety · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected April 15, 2024

Inspected September 15, 2023

5 citations · Health
D
F0638 No actual harm with potential for more than minimal harm · Isolated

Assure that each resident’s assessment is updated at least once every 3 months.

Deficient, Provider has date of correction · corrected October 12, 2023
D
F0644 No actual harm with potential for more than minimal harm · Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Deficient, Provider has date of correction · corrected October 12, 2023
D
F0645 No actual harm with potential for more than minimal harm · Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Deficient, Provider has date of correction · corrected October 12, 2023
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected October 12, 2023
D
F0812 No actual harm with potential for more than minimal harm · Isolated

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected October 12, 2023

Penalties

DateTypeAmount
April 12, 2024Fine$8,632