A middle-range Medicare rating. Review each component and visit in person before deciding.
based on 242 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
Staff turnover reported at 21%
Legend Oaks Healthcare and Rehabilitation West San Antonio has a middle-range Medicare overall rating. Strengths include clean and well-maintained facility. Some reviewers note concerns about slow nursing response to call buttons (mentioned by 4 reviewers). Review the health-inspection, staffing, and quality-measure components separately, then visit in person.
Families considering Legend Oaks will find a facility highly praised for its cleanliness, professional rehabilitation therapy, and a welcoming, friendly front-desk atmosphere. However, there are serious, recurring allegations regarding nursing responsiveness, medication administration errors, and instances of neglect during night shifts. While many residents thrive in the rehab program, some families report distressing lack of communication from case managers and clinical staff.
Quality Themes
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Concerns
Rating Trends
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Distribution · 217 analyzed
The owner provides personalized responses that mirror the specific details and sentiment of the reviewer's comments. For negative reviews, they use a consistent empathetic template that acknowledges the distress and invites direct communication to resolve issues.
Personalized based on this facility's data
Key Review Excerpts
“The physical therapy team are awesome ! China is so helpful and offering different exercises and solutions to strengthening.”
“The nurses have been responsive and actually call you back when you leave a message (as long as your phone call doesn't get dropped).”
“They forced pills down my mom's throat, which made her Vomit. I will contacting the news media and lawyer.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
12
measures
2
measures
3
measures
Residents whose walking got worse
Residents on antipsychotic medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on anti-anxiety or sleep medication
Residents vaccinated for pneumonia
Residents whose bladder or bowel control 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
Detailed Medicare record · up to 3-year lookback
Three families filed complaints triggering federal investigations, including concerns about accident prevention and infection control. The facility shows recurring issues with resident care planning, safety supervision, and infection prevention across multiple surveys from 2022 to 2024. While all deficiencies have correction dates, the pattern of repeated problems in core care areas suggests ongoing quality challenges that families should carefully consider.
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Ensure residents have reasonable access to and privacy in their use of communication methods.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Federal Penalties
Fine
Apr 12, 2024
$8,632
Dewitt Medical District
for profit
BERTETTI HEALTHCARE, INC
ROBERT GRAY
The Ensign Group
346 facilities nationwide
Chain avg rating: 2.9/5 · Rank 1 of 84 (Highest rating)
Owners
Dewitt Medical District
Owner (parent company) · Organization
Key personnel
Contact this facility directly and verify the details that matter most to your family.
Medicare Care Compare
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Google Reviews
242 reviews from families & visitors
Official Website
Visit legendwestsanantonio.com
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EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Some summaries, interpretations, suggested questions, and pricing research are AI-generated or AI-assisted and may contain errors or omit important context. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
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