Cycle 1
Health 2024-10-31 · Fire 2024-10-31
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
San Antonio, TX
Legend Oaks Healthcare and Rehabilitation - West S
5-star overall rating with 4-star inspections with $8,632 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
222 Bertetti Dr, San Antonio, TX
(210) 673-1700
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2012-05-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.46
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,097
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.76% · Performance 22.38% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.71% · Performance 8.89% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.21
Baseline 35.37% · Performance 34.21% · Measure score 7.21 · Achievement 7.21 · Improvement 0.60
Adjusted total nurse staffing
0
Baseline 3.16 hours · Performance 3.03 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.54% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 11.36% · Lower 95% interval 7.67% |
| Discharge to community | 62.18% |
50.57%
11.6 pts better
|
Better than the National Rate · Eligible stays 66 · Observed rate 57.58% · Lower 95% interval 51.23% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.97% |
95.27%
1.7 pts better
|
Numerator 64 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 59.09% |
53.69%
5.4 pts better
|
Numerator 26 · Denominator 44 |
| Discharge mobility score | 38.64% |
50.94%
12.3 pts worse
|
Numerator 17 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 66 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.89% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 13.33% · Lower 95% interval 4.87% |
| Staff COVID-19 vaccination coverage | 36.24% |
8.2%
28 pts better
|
Numerator 54 · Denominator 149 |
| Staff flu vaccination coverage | 9.04% |
42%
33 pts worse
|
Numerator 17 · Denominator 188 |
| Discharge function score | 72.73% |
56.45%
16.3 pts better
|
Numerator 32 · Denominator 44 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 11.76% |
25.2%
13.4 pts worse
|
Numerator 4 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.1
1.3 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
97.1%
2.6 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.8% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.3%
2.7 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.7% |
2.7%
3 pts worse
|
11.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 5.7% · Q3 6.5% · Q4 2.6% · 4Q avg 5.7% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
3.3%
1.5 pts worse
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 3.3% · Q3 8.3% · Q4 0.0% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
18.9%
7.5 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 9.2% · Q3 9.6% · Q4 15.1% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.6% |
10.8%
7.2 pts better
|
16.7%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 4.4% · Q3 3.3% · Q4 5.2% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 39.5% |
15.4%
24.1 pts worse
|
16.3%
23.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 41.0% · Q4 49.9% · 4Q avg 39.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
16.1%
0.9 pts better
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 18.0% · Q3 21.7% · Q4 10.0% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
0.8%
1.5 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 2.4% · Q4 5.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
15.0%
6.2 pts worse
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 19.8% · Q3 16.2% · Q4 10.4% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
4.2%
1.5 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.8% · Q3 2.5% · Q4 2.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
89.7%
9.3 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 99.4% · Q3 99.2% · Q4 98.4% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
12.0%
0.4 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 11.1% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.1% |
88.0%
10.1 pts better
|
79.7%
18.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.2% |
25.9%
0.3 pts worse
|
23.9%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.2% · Observed 26.7% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-15 · Fire 2023-09-15
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-07-15 · Fire 2022-07-15
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-10
F · Potential for more than minimal harm
2024-10-31
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-22
J · Immediate jeopardy
2024-04-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-04-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-15
D · Potential for more than minimal harm
2023-09-15
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-15
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-12
D · Potential for more than minimal harm
2022-07-15
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-07-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-11
Penalties and ownership
What sits behind the stars
$8,632
2024-04-12
Fine
Fine · fine $8,632
Fine
Ownership
Dewitt Medical District
5% Or Greater Indirect Ownership Interest · Organization
Alexander, Alma
Corporate Officer · Individual
Bertetti Healthcare, Inc.
Operational/Managerial Control · Organization
Burnam, Soon
Corporate Officer · Individual
Gray, Robert
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Mansoor, Saad
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
The Mission At Blue Skies Of Texas East
San Antonio, TX
3-star overall rating with 3-star inspections with $17,345 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Lakeside Nursing And Rehabilitation Center
San Antonio, TX
5-star overall rating with 4-star inspections with $14,611 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Westover Hills Rehabilitation And Healthcare
San Antonio, TX
4-star overall rating with 3-star inspections with $20,156 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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