The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited July 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
Nursing home report
LEGEND OAKS HEALTHCARE AND REHABILITATION CENTER -
SAN ANTONIO, TX · Medicare-certified · 126 beds
In good standing
For-profitChain member
5 of 5 overall
5/5 stars overall. Legend Oaks Healthcare and Rehabilitation Center has strong health inspection and quality ratings, no fines in the last 24 months, but staffing is rated 2/5 with reported nurse staffing below the federal benchmark (3.45 vs 4.1 hours per resident per day); recent inspection citations included food safety, continence/catheter care, and admission planning.
Facility ratings
Health inspections
Staffing
3.4541 hrs/resident/day
Quality measures
Last inspection: December 4, 2025Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.4541.
Staffing detail
- Registered nurses
- 0.47
- Licensed practical nurses
- 1.05
- Nurse aides
- 1.93
- Weekend nursing
- 3.01
Hours per resident per day.
Total staff turnover: 40%
Registered nurse turnover: 36%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
1.2%Steady
Residents with a fall causing major injury
2.6%Worsening
Residents with pressure ulcers (bedsores)
2.2%Improving
Residents with a urinary tract infection
0%Steady
Residents who lost too much weight
4.6%Worsening
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
7.2%Improving
Residents whose ability to walk got worse
8%Worsening
Show all measures
Long-stay residents on antianxiety or sleep medication
12.2%Worsening
Short-stay residents newly given an antipsychotic
0.3%Steady
Residents with a long-term catheter
0%Steady
Residents with new or worsening incontinence
5.3%Improving
Residents with depressive symptoms
2.9%Steady
Long-stay residents given the seasonal flu vaccine
100%Steady
Long-stay residents given the pneumonia vaccine
100%Steady
Short-stay residents given the seasonal flu vaccine
99.2%Steady
Short-stay residents given the pneumonia vaccine
99.9%Steady
What the inspectors found
The home failed to provide proper bladder and bowel care, including catheter care and steps to prevent urinary tract infections. Cited December 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 690 — 42 CFR §483.25(e) — S/S: E
The home failed to create and carry out a timely plan to meet a new resident’s most immediate needs after admission. Cited September 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 655 — 42 CFR §483.21 — S/S: E
The home failed to assess bed rail safety, review the risks and benefits, get informed consent, or properly install and maintain the rail. Cited September 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 700 — 42 CFR §483.25(n) — S/S: E
The nursing home failed to ensure residents had routine and emergency dental care available when needed. Cited March 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 790 — 42 CFR §483.55 — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 8 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 8 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
Operator & ownership
- Ownership
- For profit - Individual
- Chain
- Part of THE ENSIGN GROUP · 338 homes · 3.2 stars avg
- Occupancy
- 113.7 residents on an average day (90% of 126 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 19 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.