The Mission at Blue Skies of Texas East
San Antonio · 1.2 mi · 80 beds
Citations0Substantiated0
Legend Oaks Healthcare and Rehabilitation - West S
222 Bertetti Dr, San Antonio, TX, 78227
Nursing home124 licensed beds0 citations on record
6 more within 6 milesOpen in Maps
Has this facility been cited?
Yes. Federal inspectors cited 9 deficiencies against Legend Oaks Healthcare and Rehabilitation - West S in San Antonio, Texas at its most recent standard inspection on 2026-01-29, 3 of them arising from complaints. 1 finding has been recorded at the immediate-jeopardy level, the most serious CMS uses, meaning a resident was placed in immediate danger. Medicare has fined it 1 time, totalling $8,632. Medicare rates it 3 out of 5 overall.
3 / 5Medicare overall rating
124certified beds
9deficiencies at the last inspection
1immediate-jeopardy findings on record
0actual-harm findings on record
1federal fines, $8,632
What the inspectors found
Every deficiency on record, by how serious CMS judged it
CMS grades each finding from A to L on two axes: how badly residents were affected, and how many. These are its bands, not ours. The figures cover every standard and complaint survey on record, which is a longer window than the rating cycle above.
Immediate jeopardyA resident was placed in immediate danger. The most serious band CMS uses.1
Actual harmA resident was harmed, but not placed in immediate danger.0
Potential for more than minimal harmNo resident was harmed, but the failing could have caused it.17
Potential for minimal harmThe least serious band.0
Most recentDDEEEEDDDFDJDDDDDD
The last 18 findings, newest first
Each is the federal requirement the home was found not to meet, in CMS’s own wording, with the tag number so it can be looked up against the inspection report.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · F0690 · 2026-04-23 · from a complaint · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2026-04-23 · from a complaint · No actual harm, potential for more than minimal harm
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · F0641 · 2026-01-29 · standard survey · No actual harm, potential for more than minimal harm
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.
Pharmacy Service Deficiencies · F0761 · 2026-01-29 · standard survey · No actual harm, potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · F0812 · 2026-01-29 · standard survey · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2026-01-29 · standard survey · No actual harm, potential for more than minimal harm
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies · F0628 · 2026-01-29 · standard survey · No actual harm, potential for more than minimal harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · F0755 · 2026-01-29 · standard survey · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2025-12-09 · from a complaint · No actual harm, potential for more than minimal harm
Ensure residents have reasonable access to and privacy in their use of communication methods.
Resident Rights Deficiencies · F0576 · 2024-10-31 · standard survey · No actual harm, potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · F0657 · 2024-10-31 · standard survey · No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2024-04-12 · from a complaint · Immediate jeopardy to resident health or safety
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · F0609 · 2024-04-12 · from a complaint · No actual harm, potential for more than minimal harm
Assure that each resident’s assessment is updated at least once every 3 months.
Resident Assessment and Care Planning Deficiencies · F0638 · 2023-09-15 · standard survey · No actual harm, potential for more than minimal harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · F0644 · 2023-09-15 · standard survey · No actual harm, potential for more than minimal harm
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · F0645 · 2023-09-15 · standard survey · No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2023-09-15 · standard survey · No actual harm, potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · F0812 · 2023-09-15 · standard survey · No actual harm, potential for more than minimal harm
Medicare’s own rating
How CMS scores this home
These stars are Medicare’s, not ours — we publish no rating of our own. They are reproduced here because they are part of the public record.
OverallCombines the three below3 of 5
Health inspectionBased on the last three inspection cycles3 of 5
StaffingNurse hours per resident, adjusted for how sick residents are3 of 5
Quality measuresResident outcomes reported by the home4 of 5
Nurse hours per resident per dayReported by the home to CMS3.6379
Nursing staff turnoverShare of nursing staff who left in a year20.7%
Penalties
What Medicare has fined this home
FinesCivil money penalties imposed by CMS1
Total fined$8,632
Payment denials and other penaltiesMedicare refusing to pay for new admissions is the usual one1
Ownership
Who owns Legend Oaks Healthcare and Rehabilitation - West S
Nursing homes are frequently owned through layers of companies, and the name over the door is rarely the one that holds the licence. This is the ownership CMS has on file.
| Owner | Role | Share | Since |
|---|---|---|---|
| DEWITT MEDICAL DISTRICT | Organization | 100% | since 04/01/2017 |
| GRAY, ROBERT | Individual | NOT APPLICABLE | since 12/15/2017 |
| MANSOOR, SAAD | Individual | NOT APPLICABLE | since 09/12/2023 |
| ALEXANDER, ALMA | Individual | NOT APPLICABLE | since 05/27/2020 |
| BURNAM, SOON | Individual | NOT APPLICABLE | since 04/01/2017 |
| KEETCH, CHAD | Individual | NOT APPLICABLE | since 03/01/2011 |
| BERTETTI HEALTHCARE, INC. | Organization | NOT APPLICABLE | since 04/01/2017 |
| GRAY, ROBERT | Individual | NOT APPLICABLE | since 12/15/2017 |
| MANSOOR, SAAD | Individual | NOT APPLICABLE | since 09/12/2023 |
| BERTETTI HEALTHCARE, INC. | Organization | NOT APPLICABLE | since 10/24/2025 |
| ENSIGN SERVICES INC | Organization | NOT APPLICABLE | since 05/01/2016 |
| NATIONAL HEALTH INVESTORS, INC. | Organization | NOT APPLICABLE | since 04/01/2017 |
Part of the THE ENSIGN GROUP group.
Nearby
Other licensed providers within six miles
Listed by distance. Nobody paid to appear here and the order is not for sale.
Lakeside Nursing and Rehabilitation Center
San Antonio · 2.3 mi · 118 beds
Citations0Substantiated0
Harbor Valley Health and Rehabilitation
San Antonio · 4.4 mi · 120 beds
Citations0Substantiated0
Las Colinas of Westover
San Antonio · 4.9 mi · 140 beds
Citations0Substantiated0
San Antonio West Nursing and Rehabilitation
San Antonio · 5.9 mi · 135 beds
Citations0Substantiated0
Silver Creek Nursing and Rehabilitation
San Antonio · 6.0 mi · 120 beds
Citations0Substantiated0
Contact
Ask Legend Oaks Healthcare and Rehabilitation - West S a question
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Source: Centers for Medicare & Medicaid Services, Nursing Home Care Compare. Retrieved 2026-07-29. Facility number 676312.
Figures reproduce the state’s own totals and are not re-aggregated. Methodology · Report a correction