Legend Oaks Healthcare and Rehabilitation Center -
2003 W Hutchins Place, San Antonio, TX 78224
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Follow this homeLegend Oaks Healthcare and Rehabilitation Center - is a nursing home in San Antonio, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating4 of 5
- Last standard health inspectionDecember 4, 2025 (11 months ago)
- Health citations since July 28, 202332 (Texas average 28)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of October 8, 2026
Name
CMS lists a new legal business name for this home.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 5 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on May 15, 2026
7 citationsCMS lists this as a complaint inspection.
Show the 7 citations
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on May 16, 2026.
CMS has cited this home for F0558 2 times since 2023.
Citation F0573. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
CMS lists it as corrected on May 16, 2026.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on May 16, 2026.
CMS has cited this home for F0583 2 times since 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 16, 2026.
CMS has cited this home for F0689 2 times since 2023.
Citation F0805. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on May 16, 2026.
Citation F0577. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
CMS lists it as corrected on May 16, 2026.
Citation F0693. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS lists it as corrected on May 16, 2026.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Health inspection on December 4, 2025
8 citationsCMS lists this as a standard inspection.
Show the 8 citations
Citation F0690. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on December 30, 2025.
CMS has cited this home for F0690 2 times since 2024.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on December 30, 2025.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on December 30, 2025.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on December 30, 2025.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on December 30, 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 30, 2025.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on December 30, 2025.
CMS has cited this home for F0812 3 times since 2023.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on December 30, 2025.
Fire safety inspection on December 4, 2025
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on December 30, 2025.
CMS has cited this home for K0355 2 times since 2024.
Citation K0211. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on December 30, 2025.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
CMS update of February 26, 2025
Star rating
The CMS health inspection star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of December 20, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
Health inspection on September 27, 2024
8 citationsCMS lists this as a standard inspection.
Show the 8 citations
Citation F0655. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on October 20, 2024.
Citation F0700. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
CMS lists it as corrected on October 20, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on October 20, 2024.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS lists it as corrected on October 20, 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on October 20, 2024.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on October 20, 2024.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
CMS lists it as corrected on October 20, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 20, 2024.
Fire safety inspection on September 27, 2024
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on October 20, 2024.
Citation K0917. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure electrical receptacles or cover plates have distinctive color or marking.
CMS lists it as corrected on October 20, 2024.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on October 20, 2024.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on March 22, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0790. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide routine and 24-hour emergency dental care for each resident.
CMS lists it as corrected on March 26, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 26, 2024.
CMS update of December 21, 2023
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Health inspection on July 28, 2023
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on August 16, 2023.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on August 16, 2023.
Citation F0636. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS lists it as corrected on August 16, 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on August 16, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 16, 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on August 16, 2023.
Citation F0712. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
CMS lists it as corrected on August 16, 2023.
CMS star ratings
- 4 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (210) 927-0800
- Last standard health inspection
- December 4, 2025 (11 months ago)
- Certified beds
- 126
- Residents per day, on average
- 112
- Ownership type
- For profit - Individual
- Legal business name
- Legal Business Name Not Available
- Chain
- The Ensign Group
- Takes part in
- Medicare and Medicaid
More health citations than the Texas average (32 vs 28).
Questions
When was Legend Oaks Healthcare and Rehabilitation Center - last inspected?
CMS lists December 4, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Legend Oaks Healthcare and Rehabilitation Center - have?
CMS lists 32 health citations since July 28, 2023. CMS also calls these deficiencies.
Has Legend Oaks Healthcare and Rehabilitation Center - been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Legend Oaks Healthcare and Rehabilitation Center -?
Its CMS overall star rating is 4 of 5.
Is Legend Oaks Healthcare and Rehabilitation Center - a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.