Hearth Record

Legend Oaks Healthcare and Rehabilitation Center -

A nursing home in San Antonio, Texas 78224

2003 W Hutchins Place, San Antonio, Texas 78224. (210) 927-0800.

CMS’s own record, on Care Compare

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The short answer

Record last released by CMS on Oct 28, 2026.

The last 24 months 25 citations in 4 months of the last 36. Last cited May 2026. Most serious: no actual harm, potential for more than minimal harm (D). Every month

Each figure’s source sits beside it, in its section below.

What these words mean7
Star ratings
CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
Inspection (survey)
A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
Deficiency, citation, violation
What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
Scope and severity (A to L)
CMS grades each nursing home deficiency with a letter. A to C: no actual harm, with potential for minimal harm. D to F: no actual harm, but potential for more. G to I: actual harm. J to L: immediate jeopardy. Within each band, the letter rises as more residents were affected or could be: one or a few, a pattern, or widespread. Source: CMS, nursing home scope and severity grid (State Operations Manual, chapter 7).
Nurse staffing hours
The hours registered nurses, licensed practical nurses and nurse aides worked, per resident per day, from the payroll records each home sends CMS. Source: CMS, Payroll-Based Journal.
Fines and payment denials
A fine (civil money penalty) is money CMS makes a nursing home pay when it falls short of federal rules. A payment denial means Medicare and Medicaid stop paying for new admissions until the home meets the rules again. Source: CMS; 42 CFR 488.430 and 488.417.
Capacity
The most people the licence or certification lets the place care for at once: residents, children, beds or apartments, as the state counts them. It isn’t how many are there now. Source: Each state’s licensing agency.

What did inspectors find?

15 health citations at the latest inspection cycle

The Texas average is 9.6.

Last standard inspection Dec 4, 2025.

Most serious in three years: D: no actual harm, potential for more than minimal harm.

Source:

CMS, Provider Information, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

When those citations happened

25 citations in 4 months of the last 36. Last cited May 2026. Most serious: no actual harm, potential for more than minimal harm (D). The last 3 years, to Nov 5, 2026.

25 citations by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

All 25 citations in the last three years

Grouped by inspection, newest first. Each carries , from A, the least serious, to L, the most. 9 came from complaint inspections.

Source:

CMS, Health Deficiencies. Released Oct 28, 2026. Updated monthly.

May 15, 2026: complaint inspection7 citations
  • Reasonably accommodate the needs and preferences of each resident.

    Rule F0558. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 16, 2026.

  • Let each resident or the resident’s legal representative access or purchase copies of all the resident’s records.

    Rule F0573. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 16, 2026.

  • Keep residents’ personal and medical records private and confidential.

    Rule F0583. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 16, 2026.

  • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Rule F0689. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 16, 2026.

  • Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

    Rule F0805. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 16, 2026.

  • Allow residents to easily view the nursing home’s survey results and communicate with advocate agencies.

    Rule F0577. B: no actual harm, potential for minimal harm. From a complaint. Correction date, as CMS recorded it: May 16, 2026.

  • Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

    Rule F0693. B: no actual harm, potential for minimal harm. From a complaint. Correction date, as CMS recorded it: May 16, 2026.

Dec 4, 2025: standard inspection8 citations
  • Allow residents to self-administer drugs if determined clinically appropriate.

    Rule F0554. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 30, 2025.

  • Keep residents’ personal and medical records private and confidential.

    Rule F0583. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 30, 2025.

  • Ensure each resident receives an accurate assessment.

    Rule F0641. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 30, 2025.

  • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Rule F0690. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 30, 2025.

  • Ensure medication error rates are not 5 percent or greater.

    Rule F0759. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 30, 2025.

  • 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.

    Rule F0761. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 30, 2025.

  • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Rule F0812. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 30, 2025.

  • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Rule F0842. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 30, 2025.

Sep 27, 2024: standard inspection8 citations
  • 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.

    Rule F0578. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 20, 2024.

  • Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted

    Rule F0655. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 20, 2024.

  • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Rule F0690. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 20, 2024.

  • Provide safe, appropriate dialysis care/services for a resident who requires such services.

    Rule F0698. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 20, 2024.

  • Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

    Rule F0700. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 20, 2024.

  • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Rule F0812. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 20, 2024.

  • Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

    Rule F0849. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 20, 2024.

  • Provide and implement an infection prevention and control program.

    Rule F0880. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 20, 2024.

Mar 22, 2024: complaint inspection2 citations
  • Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

    Rule F0656. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 26, 2024.

  • Provide routine and 24-hour emergency dental care for each resident.

    Rule F0790. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 26, 2024.

Is it certified, and in good standing?

  • Certified for Medicare and Medicaid since Oct 10, 2006.
  • Not on CMS’s special focus list.
  • No abuse icon from CMS.
  • No change of ownership in the last 12 months.
  • CMS lists its ownership as for profit, individual.
  • 126 certified beds.
Source:

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

Has it been fined or penalized?

  • No fines in the last three years.
  • No Medicare payment denials in the last three years.
  • 9 citations in the last three years came from complaint inspections.
Source:

CMS, Penalties and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

Who does the caring?

3.62 nurse hours per resident per day

The Texas average is 3.42.

CMS publishes staffing about four months after the fact.

Source:

CMS, Provider Information and State and US Averages. Released Oct 28, 2026. Updated monthly.

Staffing measures
MeasureThis homeTexas average
Nurse hours per resident per day3.623.42
Of which registered nurses0.450.44
At weekends3.172.99
Nursing staff turnover34.7%50.8%
Registered nurse turnover25%49.8%
Administrators who left0Not given

Who owns it?

  • Dewitt Medical District owns 100% directly since Apr 1, 2017.
  • Hutchins Healthcare Inc. runs it.
  • 9 owners or officers are people: Fernando Martinez (runs it (operational or managerial control)); Fernando Martinez (on the governing body (managing control)); Fernando Martinez (additional disclosable party (controls, leases property to, or provides services to the home)); Alma Alexander (corporate officer); Chad Keetch (corporate officer); Pradeep Yamsani (runs it (operational or managerial control), 0%); Pradeep Yamsani (on the governing body (managing control)); Pradeep Yamsani (additional disclosable party (controls, leases property to, or provides services to the home)); Soon Burnam (corporate officer).
  • Part of The Ensign Group (347 homes in CMS’s data).
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, All Owners. Checked Nov 5, 2026. Updated monthly.

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

Organisations CMS lists
OrganisationRoleShareSince
Dewitt Medical DistrictOwns 5% or more directly100%Apr 1, 2017
Hutchins Healthcare Inc.Runs it (operational or managerial control)100%Apr 1, 2017
National Health Investors, Inc.Additional disclosable party (controls, leases property to, or provides services to the home)Apr 1, 2017
Texas Nhi Investors, LLCAdditional disclosable party (controls, leases property to, or provides services to the home)Apr 1, 2017
Ensign Services Inc.Additional disclosable party (controls, leases property to, or provides services to the home)May 1, 2016
Hutchins Healthcare Inc.Additional disclosable party (controls, leases property to, or provides services to the home)Oct 24, 2025

How do residents fare?

  • CMS rates its quality measures 5 of 5 (Texas average 3.8).
Source:

CMS, Provider Information and State and US Averages. Released Oct 28, 2026. Updated monthly.

CMS’s star ratings, from 1 to 5
MeasureRating
Overall rating4 of 5
Health inspections3 of 5
Staffing2 of 5
Quality measures5 of 5

How does it compare nearby?

  • Among the 12 nearest homes, within 7.0 miles, this one had the 5th most health citations at the latest inspection cycle (15; the middle value was 14.5).
Source:

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

What the record doesn’t say

  • Complaints that didn’t lead to a citation aren’t published.
  • Inspections reach CMS’s data about six weeks after they happen, and staffing about four months after.
  • CMS publishes the inspectors’ full written findings in a separate monthly file, which isn’t loaded yet.
  • Fines and Medicare payment denials are the only enforcement CMS publishes; state licence actions aren’t included.

Sources

  • Centers for Medicare & Medicaid Services, Provider Information (4pq5-n9py).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, Health Deficiencies (r5ix-sfxw).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, Penalties (g6vv-u9sr).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, All Owners (afe44b85-cc6d-40d7-b5df-00ae8910d1d2).

    Checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, State and US Averages (xcdc-v8bm).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.

Source:

This copy of the record was made on Nov 5, 2026.

From the home

The public record above comes first. Anything the home adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the home will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.

Paid listing

None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the home”, and paying will never change a finding, a rating or the order of results.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

1 of 4

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Who published it, when, and how often it changes sit beside each fact, with a link to the agency’s own file.

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