222 Bertetti Dr, San Antonio, TX 78227 · Bexar County · (210) 673-1700
124 certified beds, about 109 residents a day · For profit - Corporation · Medicare and Medicaid since 2012
CMS Care Compare ratings, data as of September 1, 2026 · CCN 676312 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on January 29, 2026, inspectors cited 6 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 20 health citations since September 2023, 1 was rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $8,632 in the last three years; the largest was $8,632, and the latest is dated April 12, 2024.
Nurses and nurse aides worked 3.64 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.53 of those hours.
20.7% of nursing staff left within the year CMS measured (Texas average 55.3%).
CMS links it to The Ensign Group, an affiliated group of 344 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 20 health citations on file.
Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #1) out of 6 residents reviewed for dignity. The facility failed to comply with Resident #1's request not to have CNA G assigned to her care and to not enter her room. This failure could place residents at risk of diminished dignity and affect their quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately but not later than 2 hours (for an injury of unknown origin involving serious bodily injury) or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 (Resident #1) out of 6 residents reviewed for abuse. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #2) reviewed for urinary catheters. The facility failed to ensure CNA A performed proper catheter care for Resident #2 when she did not protect the catheter tubing from unnecessary tension while performing catheter care. This failure could result in the unintentional dislodgement of the urinary catheter or pain/injury to a resident's urinary tract.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) reviewed for infection prevention. The facility failed to ensure CNA B wore proper PPE while providing care to Resident #1 who had a catheter and was on enhanced barrier precautions. This failure could result in the spread of infection.
Inspectors wroteBased on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 6 residents (Resident #17, Resident #78, and Resident #108) who were reviewed for resident assessments. 1. The facility failed to correctly document Resident #17's use of insulin injections on the quarterly MDS assessment. 2. The facility failed to correctly document Resident #78's use of insulin injections on the quarterly MDS assessment. 3. The facility failed to correctly document Resident #108's use of insulin injections on the quarterly MDS assessment. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 7 nurse medication cart (200/300 hall medication cart and 300 hall nurse medication cart) and 1 of 4 Residents (Resident #148) reviewed for storage of drugs. 1. The facility failed to ensure an insulin pen in the 300-hall cart was dated with an open date once it was removed from the fridge and placed in the cart for use. 2. The facility failed to ensure the 300-hall nurse medication cart did not contain loose pills. 3. The facility failed to ensure the 200/300 medication hall cart did not contain a pill cutter with an unknown white residue. 4. The facility failed to ensure Resident #148 did not have medication in her room. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to date food items in the kitchen pantry. 2. Dietary Aide F failed to correctly secure their hairnet in the kitchen. 3. The facility failed to date items in the nourishment refrigerator. 4. The facility failed to seal items in the kitchen freezer. This deficient practice could place residents at risk for food borne illness.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 4 residents (Resident #96, #14, and #108) reviewed for infection control:1. a. The facility failed to ensure Resident #96's indwelling urinary catheter bag was not on the floor and CNA A wore the proper PPE while handling Resident #96's indwelling urinary catheter bag who was on EBP.b. The facility failed to ensure CNA C used appropriate hand hygiene between glove changes and when moving from a soiled area to a clean area when providing catheter/incontinent care to Resident #96.2. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the transfer or discharge is documented in the resident's medical record, for 1 of 1 residents (Resident #123), in the facility reviewed for discharges. The facility failed to complete a discharge MDS for Resident #123. This failure could place residents at risk for inaccuracy of their health record.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 medication carts (300 hall nurse medication cart) reviewed for medications and pharmacy services, in that: The facility failed to ensure the controlled drugs-count record was not signed prior to the shift change. This failure could place residents at risk for not receiving therapeutic effects.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Residents #1) reviewed for infection control:The facility failed to ensure CNA A utilized hand hygiene between glove changes during peri-care on Resident #1. This failure could place residents at-risk for infection due to lack of hand hygiene and could result in infection or illness.
Inspectors wroteBased on interview and record review, the facility failed to promote the residents' right to receive mail, for all facility residents, in that: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life.
Inspectors wroteBased on observation's, interview's, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 12 Residents (Resident #28) whose records were reviewed for care plan revision/timing: The facility failed to ensure Resident #28's care plan was revised the reflect use of locked box. These deficient practices could affect any resident and contribute to Residents not receiving the care and services they needed.
Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 5 residents (Resident #1 and Resident #2) reviewed for adequate supervision in that: The facility did not put in place adequate supervision for Resident #1 who had a history of suicidal ideations and a Major Depression diagnosis. On 03/21/24 at 10:30 AM, he was found slumped over on a W/C in his room after he tried to commit suicide by ingesting mouthwash. He was sent to the ER before law enforcement did an emergency detention for suicide attempt. The facility did not put in place adequate supervision for Resident #2 with a diagnosis of Major Depression and was not aware of items brought in from the outside that could pose a danger of self-harm for Resident #2. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 5 residents (Resident #1) reviewed for reporting of suicidal attempt, in that: On 03/21/24, the facility did not report to the State Survey Agency (HHSC) (Health and Human Services Commission) a complaint of Resident #1 attempting suicide in the facility by ingesting mouthwash. This failure could place residents at risk for harm to include neglect, a diminished quality of life, and possible death.
Inspectors wroteBased on interview and record review, the facility failed to assess each resident quarterly (every 3 months) using the Minimum Data Set form specified by the state and approved by CMS for 1 of 36 residents (Resident #10) reviewed reviewed for quarterly assessments, in that: Resident #10's Quarterly MDS Assessment was not completed within 92 days of the previous quarterly assessment. This failure could place residents at-risk of not having their assessments completed timely.
Inspectors wroteBased on interview and record review the facility failed to refer a resident with newly evident or possible serious mental disorder for a PASRR Level II resident review upon a significant change of condition for 1 of 2 Residents (Resident #59) reviewed for PASRR (Preadmission Screening and Resident Review Services). The MDS Coordinator failed to refer Resident #59 for a resident review after being diagnosed with major depression, recurrent (04/02/21), major depressive disorder, recurrent, severe with psychotic symptoms (12/29/21) and schizoaffective disorder, (03/18/22). This deficient practice could place residents at risk of not receiving the needed PASRR services.
Inspectors wroteBased on interview and record review, the facility failed to ensure they transmitted a PASSR evaluation on newly admitted resident for 1 of 4 residents (Resident #69) reviewed for PASRR screenings. The facility failed to ensure that the initial PASRR screening (Level 1 Screening) was transmitted to the Local Mental Health Authority: This failure could place the residents at risk of not receiving specialized and/or habilitative services as need to meet their needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 32 residents (Resident # 5) reviewed for accidents and hazards. The facility failed to ensure Resident #5 did not have four disposable razors in the room. The failure could place residents at risk of harm or injury and contribute to avoidable accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 2 nourishment rooms reviewed for dietary sanitation in that: The facility failed to maintain the cleanliness of the ice maker found within the nourishment rooms. These failures could place residents at risk for foodborne illnesses such as norovirus.
3 fire safety citations on file: 2 on January 29, 2026, 1 on October 31, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| April 12, 2024 | Fine | $8,632 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Texas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.64 | 3.39 | 3.86 |
| Registered nurses | 0.53 | 0.43 | 0.69 |
| All nursing staff on weekends | 3.20 | 2.98 | 3.42 |
| Nurse aides | 2.12 | ||
| Licensed practical nurses | 0.99 | ||
| Nursing staff turnover (share who left in a year) | 20.7% | 55.3% | 45.8% |
| Registered nurse turnover | 18.2% | 54.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.24 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.81 on weekdays and 3.20 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.42 in April to June 2025 to 3.64 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.64 | 0.53 | 3.81 | 3.20 | 0.0% | 0 of 90 | 109 |
| Oct to Dec 2025 | 3.48 | 0.44 | 3.66 | 3.03 | 0.0% | 0 of 92 | 110 |
| Jul to Sep 2025 | 3.49 | 0.46 | 3.64 | 3.10 | 0.0% | 0 of 92 | 108 |
| Apr to Jun 2025 | 3.42 | 0.46 | 3.60 | 2.95 | 0.0% | 0 of 91 | 110 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Texas, Jan to Mar 2026 | 3.33 | 0.40 | 3.50 | 2.93 | 2.2% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Texas, all employers | |||
| CNAs (nursing assistants) | $18.03 | $16.97 to $20.71 | 88,680 |
| LPNs and LVNs | $29.92 | $27.46 to $32.89 | 57,560 |
| Registered nurses | $46.14 | $38.06 to $50.53 | 271,380 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Texas | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 12.9 | 15.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 3.1 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.0 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.3 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 36.3 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.6 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 3.6 | 9.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 31.8 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 10.9 | 12.3 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.3 | 2.2 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.1 | 2.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Legend Oaks Healthcare and Rehabilitation - West S's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (62.2% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
62.2% this home
Better than the national rate
US median of homes 51.5% · Texas: 116 better, 50 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 66 eligible stays.
10.5% this home
No different from the national rate
US median of homes 10.7% · Texas: 0 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 88 eligible stays.
8.9% this home
No different from the national rate
US median of homes 7.1% · Texas: 4 better, 11 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 60 eligible stays.
68.8% this home
Median of homes: Texas57.3% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 32 residents counted.
0.0% this home
Median of homes: Texas0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 55 residents counted.
0.0% this home
Median of homes: Texas1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 55 residents counted.
100.0% this home
Median of homes: Texas98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 28 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: DEWITT MEDICAL DISTRICT. CMS links this home to The Ensign Group, a group of 344 nursing homes averaging 3.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Dewitt Medical District | 5% or greater indirect ownership interest | Organization | 100% | 04/01/2017 |
| Gray, Robert | Managing control - governing body | Individual | 12/15/2017 | |
| Mansoor, Saad | Managing control - governing body | Individual | 09/12/2023 | |
| Alexander, Alma | Corporate officer | Individual | 05/27/2020 | |
| Burnam, Soon | Corporate officer | Individual | 04/01/2017 | |
| Keetch, Chad | Corporate officer | Individual | 03/01/2011 | |
| Bertetti Healthcare, Inc. | Operational/managerial control | Organization | 04/01/2017 | |
| Gray, Robert | Operational/managerial control | Individual | 12/15/2017 | |
| Mansoor, Saad | Operational/managerial control | Individual | 09/12/2023 | |
| Bertetti Healthcare, Inc. | Adp of the SNF | Organization | 10/24/2025 | |
| Ensign Services Inc | Adp of the SNF | Organization | 05/01/2016 | |
| National Health Investors, Inc. | Adp of the SNF | Organization | 04/01/2017 | |
| Texas Nhi Investors, LLC | Adp of the SNF | Organization | 04/01/2017 | |
| Gray, Robert | Adp of the SNF | Individual | 12/15/2017 | |
| Mansoor, Saad | Adp of the SNF | Individual | 09/12/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Texas. NursingHomeClear cannot take or act on complaints.