B

Legend Oaks Healthcare and Rehabilitation - West S

222 Bertetti Dr, San Antonio, TX 78227
Score: 82 / 100

Legend Oaks Healthcare And Rehabilitation - West S earns a solid B grade from CMS data, with a score of 82/100. Performing above average across most metrics, this San Antonio facility ranks in the 91th percentile among Texas nursing homes.

Staffing at Legend Oaks Healthcare And Rehabilitation - West S is near the national average, with 3.49 total nursing hours per resident per day (national average: 3.8 hours).

Recent CMS inspections identified 12 deficiencies at Legend Oaks Healthcare And Rehabilitation - West S, including 1 classified as serious — among the most concerning citation levels. The most notable finding involved: provide and implement an infection prevention and control program..

Score Breakdown

Overall CMS Rating 40 / 40 pts
5 ★ CMS rating
Health Inspections 20 / 25 pts
4 ★ inspection rating
Staffing 12 / 20 pts
3 ★ staffing rating
Quality Measures 15 / 15 pts
5 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 3.49 3.8 Average
Registered Nurses (RN) 0.46 0.7 Below Average
Licensed Practical Nurses (LPN) 1.06 0.7 Above Average
Certified Nursing Assistants (CNA) 1.96 2.4 Below Average
Weekend Total Nursing 3.10 3.8 Below Average
Weekend RN Hours 0.35 0.7 Below Average

🔍 Inspection & Deficiency History

12
Total Deficiencies
Dec 8, 2025
Most Recent Inspection
🟠 11 Moderate 🔴 1 Serious
View recent deficiencies (5 shown)
  • Tag 0880 Severity D
    Provide and implement an infection prevention and control program.
    Dec 8, 2025 · Infection Control Deficiencies
  • Tag 0576 Severity F
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    Oct 30, 2024 · Resident Rights Deficiencies
  • Tag 0657 Severity D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    Oct 30, 2024 · Resident Assessment and Care Planning Deficiencies
  • Tag 0689 Severity J
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Apr 11, 2024 · Quality of Life and Care Deficiencies
  • Tag 0609 Severity D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Apr 11, 2024 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 2.7% 4.5% Better
Falls with major injury 0.6% 3.0% Better
On antipsychotic medication 3.6% 14.5% Better
Urinary tract infections 2.3% 2.5% Average
ADL decline (daily activities) 15.2% 14.0% Average
Excessive weight loss 4.8% 7.5% Better
New/worsened incontinence 21.2% 45.0% Better

⚠️ Penalties & Fines

1 penalty recorded by CMS

Total fines: $8,632

How This Grade Was Calculated

This facility's grade of B is based on a score of 82 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 5★ → 40 pts (max 40)
  • Health Inspection Rating: 4★ → 20 pts (max 25)
  • Staffing Rating: 3★ → 12 pts (max 20)
  • Quality Measures Rating: 5★ → 15 pts (max 15)
  • Penalty deductions: -5 pts
  • Fine deductions: -0 pts

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
For profit - Corporation
Certified Beds
124
Provider Type
Medicare and Medicaid
Resident Council
Yes
Family Council
No
Sprinkler System
Yes
Last Inspection
Oct 30, 2024
Deficiencies (Cycle 1)
3