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.
based on 332 Google reviews
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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 detailsStrengths
- 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
Distribution · 223 analyzed
How They Respond to Reviews
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!”
“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.”
“The staff was very professional. The building was clean. I went to go visit a Family friend. She was well taken care of”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both 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
15
measures
2
measures
Residents on antipsychotic medication
Residents whose bladder or bowel control got worse
Residents on anti-anxiety or sleep medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents needing more daily help over time
Residents whose walking got worse
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
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, 2025Routine10
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.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
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.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Sep 27, 2024Routine11
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
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
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.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure electrical receptacles or cover plates have distinctive color or marking.
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.
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.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Mar 22, 2024Complaint2
Quality of Life and Care Deficiencies
Provide routine and 24-hour emergency dental care for each resident.
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, 2023Routine7
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
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.
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.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
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
Dewitt Medical District
for profit
HUTCHINS HEALTHCARE, INC
PETER TIERNEY
Chain Affiliation
The Ensign Group
338 facilities nationwide
Chain avg rating: 2.9/5 · Rank 9 of 84 (Best)
Ownership & Management
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
332 reviews from families & visitors
Official Website
Visit legendsouthsanantonio.com
Medicare data downloads
Original nursing home datasets
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