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Nursing HomeMedicaid Top Rated

Legend Oaks Healthcare and Rehabilitation Center San Antonio

Strong Medicare quality ratings; families often praise compassionate and attentive nursing staff. Still worth an in-person visit.

2003 W Hutchins Place, Patton Tareyton Tempo · San Antonio, TX 78224126 bedsLicensed & Active
5/5
Medicare
Inspection
Quality
Staffing
Google rating
4.1/5

based on 332 Google reviews

5
4
3
2
1

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What this means for your family

This facility is an excellent choice for rehabilitation due to its highly-rated therapy teams and clean environment. However, families should closely monitor medication administration and ensure all valuable personal items are documented, as there have been documented instances of medication errors and lost property.

Google Reviews

Google Reviews

332 reviews on Google
Families considering Legend Oaks can expect a facility highly praised for its exceptionally friendly, professional, and attentive nursing and therapy staff. While many reviewers highlight the cleanliness and the quality of the rehabilitation programs, there are significant, serious concerns regarding medication errors, delayed response to call lights, and occasional issues with the loss of personal belongings.

Quality Themes

Tap a score for details
Food4.0Staff9.0Clean9.0Activities8.0Meds3.0MemoryN/AComms4.0ValueN/A

Strengths

  • Compassionate and attentive nursing staff
  • Effective and professional physical therapy
  • Clean and well-maintained facility
  • Friendly and welcoming atmosphere

Concerns

  • Delays in responding to call lights and patient needs (mentioned by 3 reviewers)
  • Medication management errors and delays (mentioned by 2 reviewers)
  • Loss or theft of resident personal belongings (mentioned by 2 reviewers)
  • Inconsistent food quality (mentioned by 2 reviewers)
  • Communication issues with admissions and management (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2344.32024(71)4.62025(88)4.32026(64)

Distribution · 223 analyzed

5
171
4
21
3
4
2
4
1
23

How They Respond to Reviews

50%response rate
Good

The owner provides personalized responses to positive reviews by referencing specific details like staff names, cleanliness, or family members. For negative reviews, they use a consistent professional template that acknowledges the issue and requests direct contact for resolution.

Questions for Your Tour

  • 1It is wonderful to see how much the team values feedback through your review responses; how does management use resident and family input to improve daily services?
  • 2We are so impressed by the high ratings for your physical therapy department; could you tell us more about how the therapists work with residents to maintain their mobility?
  • 3With the facility being so well-maintained and clean, what specific protocols do you have in place to ensure residents' personal belongings stay safe and organized in their rooms?
  • 4How does the nursing team manage call lights and ensure that resident needs are addressed promptly, especially during busy shift changes?
  • 5Could you walk us through your process for medication administration to ensure everything is handled accurately and on schedule?
  • 6What are some of the favorite daily activities or social events that help create that friendly and welcoming atmosphere mentioned by many families?

Personalized based on this facility's data


Key Review Excerpts

The staff was very helpful in helping me find my cousin’s cell phone. They went far and beyond. Great Staff!

Family member · 2026★★★★★

My mother has late stage dementia and has been a resident of Legend Oaks for 2 years . Myself and my entire family are overwhelmed with the excellent care she has received.

Memory care family member · 2025★★★★★

The staff was very professional. The building was clean. I went to go visit a Family friend. She was well taken care of

Visitor · 2024★★★★★
Source: 332 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.47hrs
63%
Registered nurses for medical care
Total Nursing
3.45hrs
84%
All nurses + aides combined
Staff Turnover
40%
Lower is better (< 30% = good)
RN Turnover
36%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
5/ 5
Better Than Avg

15

measures

Mixed Results

2

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility1.2%
Better than Avg
Here
1.2%
US
15.4%
TX
9.4%
Bexar
10.5%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility5.3%
Better than Avg
Here
5.3%
US
19.4%
TX
14.2%
Bexar
17.2%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility12.2%
Better than Avg
Here
12.2%
US
19.5%
TX
18.4%
Bexar
21.9%
😔

Residents with depression symptoms

↓ Lower is better
This Facility2.9%
Mixed vs Avgs
Here
2.9%
US
12.1%
TX
2.5%
Bexar
2.0%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility7.2%
Better than Avg
Here
7.2%
US
14.4%
TX
16.1%
Bexar
16.1%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility8.0%
Better than Avg
Here
8.0%
US
15.3%
TX
14.9%
Bexar
14.1%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility99.2%
Better than Avg
Here
99.2%
US
79.7%
TX
88.0%
Bexar
84.4%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility99.9%
Better than Avg
Here
99.9%
US
81.8%
TX
89.2%
Bexar
81.0%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.3%
Better than Avg
Here
0.3%
US
1.6%
TX
1.5%
Bexar
2.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

8deficiencies
Near state avg (9.1)
2 complaint-triggered

This facility has a concerning pattern of recurring deficiencies across multiple surveys, with families filing complaints that triggered federal investigations into dental care and care planning issues. The most frequent problems involve food safety and dietary services, care planning and resident assessments, and fire safety equipment. While all violations show correction dates, the repeated issues with food handling across three separate surveys and ongoing problems with resident care planning suggest potential systemic challenges that families should carefully evaluate.

Dec 4, 2025Routine
10
0690Potential for harm · PatternCorrected

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.

0355Potential for harm · PatternCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0583Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0761Potential for harm · IsolatedCorrected

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.

0812Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

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

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0211Potential for harm · IsolatedCorrected

Egress Deficiencies

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

Sep 27, 2024Routine
11
0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0655Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

0700Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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

0917Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure electrical receptacles or cover plates have distinctive color or marking.

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0690Potential for harm · IsolatedCorrected

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.

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0849Potential for harm · IsolatedCorrected

Administration Deficiencies

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Mar 22, 2024Complaint
2
0790Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Jul 28, 2023Routine
7
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0636Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

0657Potential for harm · IsolatedCorrected

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.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0712Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Dewitt Medical District

Organization Type

for profit

Management Company

HUTCHINS HEALTHCARE, INC

Administrator

PETER TIERNEY

Chain Affiliation

Chain Name

The Ensign Group

Chain Size

338 facilities nationwide

Chain avg rating: 2.9/5 · Rank 9 of 84 (Best)

Ownership & Management

Key personnel

Martinez, FernandoManaging Control - Governing BodyYamsani, PradeepManaging Control - Governing BodyAlexander, AlmaOfficer / DirectorBurnam, SoonOfficer / DirectorKeetch, ChadOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

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References & Resources

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