01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-01-29 | 11 | 2026-01-29 | 2 |
| Cycle 2 | 2024-10-31 | 2 | 2024-10-31 | 1 |
| Cycle 3 | 2023-09-15 | 7 | 2023-09-15 | 0 |
CMS CCN 6763122026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Legend Oaks Healthcare And Rehabilitation - West S
222 Bertetti Dr · San Antonio, TX 78227 · Bexar County
Certified beds124CMS provider file
Recent citation rows23current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
23 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-12 · HEALTHF0550Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2026-07-03 · complaint2026-06-12 · HEALTHF0609Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2026-07-03 · complaint2026-04-23 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2026-05-14 · complaint2026-04-23 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-05-14 · complaint2026-01-29 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2026-02-182026-01-29 · HEALTHF0641Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2026-02-182026-01-29 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-02-182026-01-29 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-02-182026-01-29 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-02-182026-01-29 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-02-182026-01-29 · FIREK0211Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2026-02-182026-01-29 · FIREK0741Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2026-02-182025-12-09 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-12-10 · complaint2024-10-31 · HEALTHF0576Severity F · widespread; potential for more than minimal harm
Resident Rights Deficiencies
Ensure residents have reasonable access to and privacy in their use of communication methods.
Correction field: Deficient, Provider has date of correction · 2024-11-222024-10-31 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2024-11-222024-10-31 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2024-11-222024-04-12 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-04-15 · complaint2024-04-12 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-04-15 · complaint2023-09-15 · HEALTHF0638Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
Correction field: Deficient, Provider has date of correction · 2023-10-122023-09-15 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2023-10-122023-09-15 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2023-10-122023-09-15 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2023-10-122023-09-15 · HEALTHF0812Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2023-10-1203 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-04-12 | Fine | $8,632 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- DEWITT MEDICAL DISTRICTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 04/01/2017
- GRAY, ROBERTIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 12/15/2017
- MANSOOR, SAADIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 09/12/2023
- ALEXANDER, ALMAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/27/2020
- BURNAM, SOONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2017
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2011
- BERTETTI HEALTHCARE, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2017
- GRAY, ROBERTIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/15/2017
- MANSOOR, SAADIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/12/2023
- BERTETTI HEALTHCARE, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 10/24/2025
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2016
- NATIONAL HEALTH INVESTORS, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 04/01/2017
- TEXAS NHI INVESTORS, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/01/2017
- GRAY, ROBERTIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/15/2017
- MANSOOR, SAADIndividual · ADP OF THE SNFNOT APPLICABLE · since 09/12/2023
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.64per resident day
RN hours0.53per resident day
Weekend nurse hours3.20per resident day
Staff turnover20.7%CMS reported field
06 / LOCAL RECORDS
Open the San Antonio ledger →Other published facilities nearby
Army Residence Community91 beds · CMS overall 5/524 citation rowsAvir At Heritage150 beds · CMS overall 3/540 citation rowsAvir At San Antonio119 beds · CMS overall 1/551 citation rowsAvir At San Knoll120 beds · CMS overall 1/570 citation rowsBroadway Nursing & Rehabilitation237 beds · CMS overall 1/583 citation rowsBuena Vida Nursing And Rehab-San Antonio222 beds · CMS overall 1/557 citation rowsCoronado At Stone Oak112 beds · CMS overall 5/536 citation rowsCastle Hills Rehabilitation And Care Center143 beds · CMS overall 1/599 citation rows