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
Data as of July 1, 2026
3 of 5 overall
Legend Oaks Healthcare and Rehabilitation Center in San Antonio has a 3-out-of-5-star overall rating, with a low 2-star staffing rating and reported nurse staffing below the federal benchmark (3.62 vs. 4.1 hours per resident per day). It had 0 fines in the last 24 months; recent inspection citations involved food handling, bowel/bladder and catheter care, and admission planning.
Facility ratings
Health inspections
Staffing
3.6209 hrs/resident/day
Quality measures
Last inspection: May 15, 2026Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.6209.
Staffing detail
- Registered nurses
- 0.42
- Licensed practical nurses
- 1.24
- Nurse aides
- 1.96
- Weekend nursing
- 3.17
Hours per resident per day.
Total staff turnover: 46%
Registered nurse turnover: 33%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
2.8%2.2%Improving
Residents with a fall causing major injury
3.1%1.6%Improving
Residents with pressure ulcers (bedsores)
2%2.7%Worsening
Residents with a urinary tract infection
0%0%No change
Residents who lost too much weight
5.1%7.4%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
5.3%9.8%Worsening
Residents whose ability to walk got worse
6.9%13%Worsening
Long-stay residents on antianxiety or sleep medication
10.2%14.8%Worsening
Short-stay residents newly given an antipsychotic
0.3%0%No change
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
5.1%5.4%No change
Residents with depressive symptoms
3.4%3.6%No change
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—99.2%—
Short-stay residents given the pneumonia vaccine
100%99.8%No change
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 7 health deficiencies.
See what inspectors found
- 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 · 346 homes · 3.2 stars avg
- Occupancy
- 107.8 residents on an average day (86% 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.