Legend Oaks Healthcare and Rehabilitation West San Antonio
Meets baseline Medicare standards with room for improvement. A tour and talking to current residents' families is the best next step.
based on 237 Google reviews
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What this means for your family
This facility is an excellent choice for short-term rehabilitation, particularly for wound care and physical therapy. However, if your loved one requires high-dependency nursing, you should closely monitor call-bell response times and verify that medication protocols are strictly followed.
Google Reviews
Google Reviews
237 reviews on Google“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
Tap a score for detailsStrengths
- Clean and well-maintained facility
- Exceptional rehabilitation and physical therapy teams
- Friendly and welcoming reception staff
- Professional and compassionate wound care
Concerns
- Slow nursing response to call buttons (mentioned by 4 reviewers)
- Inconsistent communication from case managers and doctors (mentioned by 3 reviewers)
- Issues with hygiene and unpleasant odors in certain areas (mentioned by 2 reviewers)
- Staff attitude and unprofessionalism (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 212 analyzed
How They Respond to Reviews
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.
Questions for Your Tour
- 1It's wonderful to see how clean and well-maintained the facility looks; what steps do you take to ensure that high standard of cleanliness is consistent throughout all the resident areas?
- 2We've heard great things about your rehabilitation and physical therapy teams; could you tell us more about how the therapists work with residents to meet their specific recovery goals?
- 3How does the nursing team manage call buttons and response times to ensure residents feel supported and attended to throughout the night?
- 4What is your process for ensuring clear and consistent communication between the doctors, case managers, and our family members regarding changes in care?
- 5Can you walk us through your protocols for medication management to ensure everything is handled accurately and timely?
- 6What kind of daily activities or social events do you have planned to keep the residents engaged and connected with one another?
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.”
“My mother was at this rehab facility for 3 weeks. She asked me to give reviews for some outstanding care she received from the following Earth angels : Ana Rosales, Amanda Perez, Christina Perez, and Gracie!”
“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).”
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
11
measures
2
measures
4
measures
Residents whose walking got worse
Residents on antipsychotic medication
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 vaccinated for pneumonia
Residents vaccinated for the flu
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
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.
Jan 29, 2026Routine8
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.
Dec 9, 2025Complaint1
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Oct 31, 2024Routine3
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.
Apr 12, 2024Complaint4
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
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Sep 15, 2023Routine5
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
Ownership & Operations
Who Operates This Facility
Dewitt Medical District
for profit
BERTETTI HEALTHCARE, INC
ROBERT GRAY
Chain Affiliation
The Ensign Group
338 facilities nationwide
Chain avg rating: 2.9/5 · Rank 10 of 84 (Best)
Ownership & Management
Owners
Dewitt Medical District
Owner (parent company) · Organization
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
237 reviews from families & visitors
Official Website
Visit legendwestsanantonio.com
Medicare data downloads
Original nursing home datasets
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