Legend Oaks Healthcare and Rehabilitation - West S
222 Bertetti Dr, San Antonio, TX 78227
Open in mapsSee this home on CMS Care Compare
Follow this homeLegend Oaks Healthcare and Rehabilitation - West S 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 rating3 of 5
- Last standard health inspectionJanuary 29, 2026 (9 months ago)
- Health citations since September 15, 202320 (Texas average 28)
- Fines in the past three years1, $8,632 in total
- CMS flagsNone listed by CMS
Get an email when CMS publishes something new about this home
One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
Check your email
You can ask for another link in 10 minutes.
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 July 29, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Health inspection on June 12, 2026
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on July 3, 2026.
Citation F0609. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 3, 2026.
CMS has cited this home for F0609 2 times since 2024.
CMS update of April 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 staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on April 23, 2026
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
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 May 14, 2026.
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 May 14, 2026.
CMS has cited this home for F0880 3 times since 2025.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Health inspection on January 29, 2026
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation F0641. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on February 18, 2026.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
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 February 18, 2026.
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 February 18, 2026.
CMS has cited this home for F0812 2 times since 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 18, 2026.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on February 18, 2026.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on February 18, 2026.
Fire safety inspection on January 29, 2026
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0741. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on February 18, 2026.
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 February 18, 2026.
Health inspection on December 9, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
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 December 10, 2025.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Fine
CMS changed the fine from April 12, 2024 from $8,021 to $8,632.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on October 31, 2024
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation F0576. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure residents have reasonable access to and privacy in their use of communication methods.
CMS lists it as corrected on November 22, 2024.
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 November 22, 2024.
Fire safety inspection on October 31, 2024
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on November 22, 2024.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 5 of 5 to 3 of 5.
CMS update of May 29, 2024
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5.
Health inspection on April 12, 2024
2 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
411 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2024.
CMS fine of $8,632 on April 12, 2024.
Show the 2 citations
Citation F0689. Severity J: immediate jeopardy, 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 April 15, 2024.
CMS has cited this home for F0689 2 times since 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 15, 2024.
CMS update of January 31, 2024
Star rating
The CMS health inspection star rating changed from 5 of 5 to 4 of 5.
Health inspection on September 15, 2023
5 citationsCMS lists this as a standard inspection.
Show the 5 citations
Citation F0638. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assure that each resident’s assessment is updated at least once every 3 months.
CMS lists it as corrected on October 12, 2023.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on October 12, 2023.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on October 12, 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 October 12, 2023.
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 October 12, 2023.
CMS star ratings
- 3 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (210) 673-1700
- Last standard health inspection
- January 29, 2026 (9 months ago)
- Certified beds
- 124
- Residents per day, on average
- 101.5
- Ownership type
- For profit - Corporation
- Legal business name
- Dewitt Medical District
- Chain
- The Ensign Group
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Texas average (20 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- DEWITT MEDICAL DISTRICT5% or greater indirect ownership interest · 100% · since 04/01/2017
- BERTETTI HEALTHCARE, INC.Operational/managerial control · not applicable · since 04/01/2017
- GRAY, ROBERTOperational/managerial control · not applicable · since 12/15/2017
- MANSOOR, SAADOperational/managerial control · not applicable · since 09/12/2023
Questions
When was Legend Oaks Healthcare and Rehabilitation - West S last inspected?
CMS lists January 29, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Legend Oaks Healthcare and Rehabilitation - West S have?
CMS lists 20 health citations since September 15, 2023. CMS also calls these deficiencies.
Has Legend Oaks Healthcare and Rehabilitation - West S been fined?
CMS lists 1 fine in the past three years, $8,632 in total.
What is the CMS star rating of Legend Oaks Healthcare and Rehabilitation - West S?
Its CMS overall star rating is 3 of 5.
Is Legend Oaks Healthcare and Rehabilitation - West S a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.