CCN 676113

Legend Oaks Healthcare and Rehabilitation Center -

2003 W HUTCHINS PLACE, San Antonio, TX 78224 · Bexar County

Phone: (210) 927-0800
Ownership: For profit - Individual
Certified beds: 126
Residents per day: 107.8
Health citations: 32
Penalties: 0
Fines: 0 · $0
Map: Open location

Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Overall

CMS overall star rating in this file.

Health inspection

Compared with other homes in the state.

Staffing

Based on reported PBJ nurse hours.

Quality measures

Long-stay 5 · short-stay 4.

Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Staffing hours

Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.

Measure: This home; State; U.S.
Nurse aide: 1.96; 2.01; 2.32
LPN/LVN: 1.24; 0.95; 0.86
Registered nurse: 0.42; 0.43; 0.69
Total nurse staff: 3.62; 3.39; 3.86
Weekend total: 3.17; 2.98; 3.42
Weekend RN: 0.50; 0.34; 0.48

Adjusted total nurse hours: 3.20. Adjusted RN hours: 0.37. Case-mix total: 4.34. Case-mix index: 1.588.

Total nursing staff turnover: 46.2%. RN turnover: 33.3%. Administrators who left: 0.

How to read staffing hours

Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Fines and penalties

CMS reports 0 fines totaling $0, and 0 payment denials.

The Penalties file has no individual penalty rows for this CCN.

Cycle 1 standard survey: December 4, 2025. Health deficiencies counted in cycle 1: 15. Cycle 1 total health score: 56.

Cycle 2 standard survey: September 27, 2024. Cycle 2/3 health deficiencies: 10. Total weighted health survey score: 56.

Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Health inspection citations

The Health Deficiencies file lists 32 citations for this home, including 0 at immediate jeopardy and 0 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.

May 15, 2026

7 citations

Tag	What CMS cited	Scope and severity	Status
F558	Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Complaint survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · May 16, 2026
F573	Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Resident Rights Deficiencies · Complaint survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · May 16, 2026
F583	Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Complaint survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · May 16, 2026
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · May 16, 2026
F805	Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · Complaint survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · May 16, 2026
F577	Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Resident Rights Deficiencies · Complaint survey · Cycle 1	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · May 16, 2026
F693	Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · May 16, 2026

December 4, 2025

8 citations

Tag	What CMS cited	Scope and severity	Status
F690	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 · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 30, 2025
F554	Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 30, 2025
F583	Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 30, 2025
F641	Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 30, 2025
F759	Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 30, 2025
F761	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 · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 30, 2025
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 30, 2025
F842	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 30, 2025

September 27, 2024

8 citations

Tag	What CMS cited	Scope and severity	Status
F655	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F700	Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F578	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. Resident Rights Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F690	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 · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F698	Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F849	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024

March 22, 2024

2 citations

Tag	What CMS cited	Scope and severity	Status
F790	Provide routine and 24-hour emergency dental care for each resident. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · March 26, 2024
F656	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · March 26, 2024

July 28, 2023

7 citations

Tag	What CMS cited	Scope and severity	Status
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 16, 2023
F558	Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 16, 2023
F636	Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 16, 2023
F657	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 · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 16, 2023
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 16, 2023
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 16, 2023
F712	Ensure that the resident and his/her doctor meet face-to-face at all required visits. Nursing and Physician Services Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 16, 2023

Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Other facts in the provider file

Provider type: Medicare and Medicaid.
Chain name in the file: The Ensign Group (344 facilities). Chain average overall rating: 3.2.
Legal business name: Legal Business Name Not Available.
First approved for Medicare and Medicaid services: October 10, 2006.
Resident and family council: Resident.
Automatic sprinklers in all required areas: Yes.
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Questions

What is the CMS overall rating for Legend Oaks Healthcare and Rehabilitation Center -?

Legend Oaks Healthcare and Rehabilitation Center - has an overall rating of 3 out of 5. The health inspection rating is 3, staffing is 2, and the quality measure rating is 4.

How many health citations does CMS list for Legend Oaks Healthcare and Rehabilitation Center -?

The Health Deficiencies file lists 32 health citations for this home. 0 are coded immediate jeopardy (J, K, or L) and 0 are coded actual harm that is not immediate jeopardy (G, H, or I).

What nurse staffing does CMS report for Legend Oaks Healthcare and Rehabilitation Center -?

CMS reports 3.62 total nurse hours per resident per day, including 0.42 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.

CMS file

Opening the record…

September 27, 2024

8 citations

Tag	What CMS cited	Scope and severity	Status
F655	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F700	Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F578	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. Resident Rights Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F690	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 · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F698	Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F849	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 20, 2024