Legend Oaks Healthcare and Rehabilitation - West S
222 Bertetti Dr
San Antonio, TX, 78227
2106731700
CCN: 676312
5
Overall4
Health3
Staffing5
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
| Name | Role | % |
|---|---|---|
| DEWITT MEDICAL DISTRICT | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% |
| ALEXANDER, ALMA | CORPORATE OFFICER | NOT APPLICABLE |
| BURNAM, SOON | CORPORATE OFFICER | NOT APPLICABLE |
| KEETCH, CHAD | CORPORATE OFFICER | NOT APPLICABLE |
| MANSOOR, SAAD | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| BERTETTI HEALTHCARE, INC. | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| GRAY, ROBERT | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
Penalties (1)
| Date | Type | Amount |
|---|---|---|
| 2024-04-12 | Fine | $9K |
Health Deficiencies (12)
2025-12-09 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2024-10-31 · Health
D
F657 · 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.
F
F576 · Resident Rights Deficiencies
Ensure residents have reasonable access to and privacy in their use of communication methods.
2024-04-12 · Health
J
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2023-09-15 · Health
D
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F645 · Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
D
F644 · Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
D
F638 · Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
2022-07-15 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F578 · 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.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
3.49
RN Hrs/Resident/Day0.54
0.46
LPN Hrs/Resident/Day0.81
1.06
CNA Hrs/Resident/Day2.33
1.96
PT Hrs/Resident/Day0.12
0.10
Data as of 2026-03-01