Legend Oaks Healthcare And Rehabilitation West San Antonio

Penalties

• Apr 12, 2024 — Fine ($8,632)

Inspection findings

1. Jun 12, 2026 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Jul 3, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jul 3, 2026 · CMS health inspection

2. Apr 23, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0690 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.

     Corrected May 14, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 14, 2026 · CMS health inspection

3. Jan 29, 2026 Health · 8 findings
   • Not serious Scope/severity D

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Feb 18, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Feb 18, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Feb 18, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0761 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.

     Corrected Feb 18, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Feb 18, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 18, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Feb 18, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Feb 18, 2026 · CMS fire safety

4. Dec 9, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 10, 2025 · CMS health inspection

5. Oct 31, 2024 Health · 3 findings
   • Not serious Scope/severity F

     F0576 Resident Rights Deficiencies

     Ensure residents have reasonable access to and privacy in their use of communication methods.

     Corrected Nov 22, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0657 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.

     Corrected Nov 22, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Nov 22, 2024 · CMS fire safety

6. Apr 12, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Apr 15, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Apr 15, 2024 · CMS health inspection

7. Sep 15, 2023 Health · 5 findings
   • Not serious Scope/severity D

     F0638 Resident Assessment and Care Planning Deficiencies

     Assure that each resident’s assessment is updated at least once every 3 months.

     Corrected Oct 12, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Oct 12, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Oct 12, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Oct 12, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Oct 12, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• ALEXANDER, ALMA — corporate officer, NOT APPLICABLE, since 05/27/2020
• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 04/01/2017
• GRAY, ROBERT — operational/managerial control, NOT APPLICABLE, since 12/15/2017
• GRAY, ROBERT — managing control - governing body, NOT APPLICABLE, since 12/15/2017
• GRAY, ROBERT — adp of the snf, NOT APPLICABLE, since 12/15/2017
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• MANSOOR, SAAD — adp of the snf, NOT APPLICABLE, since 09/12/2023
• MANSOOR, SAAD — operational/managerial control, NOT APPLICABLE, since 09/12/2023
• MANSOOR, SAAD — managing control - governing body, NOT APPLICABLE, since 09/12/2023
• BERTETTI HEALTHCARE, INC. — adp of the snf, NOT APPLICABLE, since 10/24/2025
• BERTETTI HEALTHCARE, INC. — operational/managerial control, NOT APPLICABLE, since 04/01/2017
• DEWITT MEDICAL DISTRICT — 5% or greater indirect ownership interest, 100%, since 04/01/2017
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 05/01/2016
• NATIONAL HEALTH INVESTORS, INC. — adp of the snf, NOT APPLICABLE, since 04/01/2017
• TEXAS NHI INVESTORS, LLC — adp of the snf, NOT APPLICABLE, since 04/01/2017