Legend Oaks Healthcare and Rehabilitation Center -: Data Analysis and Ratings

CMS Five Star Rating(2 out of 5):

 2003 W HUTCHINS PLACE SAN ANTONIO, TX 78224

  210-927-0800

Data date: October 01, 2022

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The Most Important Data about Legend Oaks Healthcare and Rehabilitation Center -

We've looked at a lot of nursing homes, this is what we think you need to see first and if you don't want to spend a lot of time. (It's the tl;dr section.)

There is no indication of abuse occuring at Legend Oaks Healthcare and Rehabilitation Center -. (CMS flags facilities where abuse has either happened or is very likely.)

CMS 5-Star Overall Rating: (2 out of 5):
(The national average overall star rating is 3 stars.)

Current Trend: Worsening

Total Nursing Hours Spent Per Resident Per Day: 3.26
(The national average is 3.76 )

Best Nursing Homes in TX

According to our analysis, Legend Oaks Healthcare and Rehabilitation Center - is ranked #49 out of 74 skilled nursing homes within a 25 mile radius. See detailed information from recent inspection reports, nursing hours analysis, surverys, and information on owners and operators. Click here to view the ranked list of nursing homes near Legend Oaks Healthcare and Rehabilitation Center -.

What is this page all about?

Below is everything shred of information that we can find about Legend Oaks Healthcare and Rehabilitation Center -, along with our best effort to make sense of the data. Our purpose here is to help you to make good decisions when picking a nursing home and to keep you informed once you have chosen a home. We know from personal experience that choosing a nursing home is not something you do once and then you forget about it. In fact, it gets worse. Once you select a nursing home and get through the initial steps of figuring out how to pay for it, then the real worries start. Are they taking good care of me or my loved one? This is the question that will keep you up at night: Can I really trust these people? We wish we could answer this question, we can't. What he can do is churn through the tons of data and try and help you to make sense of it. We hope it helps.

General Data Card

These are the basic data points for the facility.

Data date: October 01, 2022

Address: 2003 W HUTCHINS PLACE

SAN ANTONIO, TX 78224

Phone: 210-927-0800

Click for Map

Ranking: Legend Oaks Healthcare and Rehabilitation Center - is ranked #22 out of 33 facilities within a 10 mile radius and #49 out of 74 facilities within a 25 mile radius.

Medicare Provider Number: 676113

Participating in Medicare Since: October 10, 2006

No. of Certified Beds: 126

No. of Residents: 109

Occupancy: 86.51 % (as of 11/13/2022 )

Amount fined in recent period: $31,757.00

Complaints filed: 0

Review of Legend Oaks Healthcare and Rehabilitation Center - Ratings and Inspection Scores

CMS regularly inspects every skilled nursing facility. (The timing is supposed to be annually, but since the beginning of the Covid pandemic, these inspections have not occured as frequently.) The results of the multi-day inspection is reduced to a series of scores which are then translated into the star ratings. The health inspection scores are an absolute value, so you can compare one facility's score directly to another. The Overall Star rating is based on the facility's performance as compared to other facilities in the same state, so you cannot easily compare one facility's Overall star rating to a facility in another state.

Ratings

Overall Rating 2:
Health Inspection Rating 2:
Quality Rating 5:
Staffing Rating 1:

Inspection Scores

Cycle 1 Score (as of March 10, 2021) 127
Cycle 2 Score (as of July 12, 2019) 20
Cycle 3 Score (as of July 26, 2018) 76
Weighted All Cycles Score 83

It has been 18 months since the most recent inspection.

What Goes Into the Nursing Home's 5-Star Rating

CMS has put a lot of effort into creating its very elaborate 5-Star Quality Rating System specifically to provide a quick way for residents and family members to easily understand how well a nursing home is performing and to make comparing nursing homes easier. The rating system allows people to easily compare facilities across numerous dimensions with the express purpose of identifying the best and best performing nursing homes. The rating system was initially developed in 2008 and the methodologies are regularly reviewed and updated.

The rating system has five separate ratings including:

  • Overall rating
  • Health Inspection rating
  • Staff rating
  • RN Staffing rating
  • Quality Measures rating

Nursing homes are rated from 1-star to 5-stars with 1-star being the best rating and 5-star being the best rating. For the Health Inspection Rating the nursing homes in each state are ranked based on their weighted three year inspection score. The top 10 percent of nursing homes (those with the lowest scores) are awarded a 5-star rating; the bottom 20 percent (those with the highest scores) are awarded a 1-star rating. In between 1-star and 5-star, the remaining homes are divided equally into three tranches which correspond with the stars 2 to 4. The staff ratings and quality measure ratings follow a similar process but the divisions are based on a national ranking. The division between star ratings is called the “cut-rate”. Cut-rates are redefined periodically and are published by CMS. See the latest cut rates on this table.

Calculating the Overall Star Rating is done differently. According to CMS, the reason for adopting a different system is to give the Health Inspection Rating higher weight in the Overall Rating. So, since there are FIVE ratings and FIVE stars for each rating, there must also be a FIVE step process to calculate the Overall Rating (so symetrical!) :

  1. Begin with the Health Inspection Rating
  2. Add one star to the Health Inspection Rating if the Staffing Rating is at least four-stars and is higher than the Health Inspection Rating. (We will call this the "Adjusted Rating".)
  3. Subtract one star from the Health Inspection Rating if the Staffing Rating is one-star.
  4. Add a star to the Adjusted Rating if the Quality Measure Rating is 5-stars.
  5. Subtract one star from the Adjusted Rating if the Quality Measure Rating is 1-star.

Throughout the calculation of the Overall Rating, the rating cannot exceed 5-stars. The Overall Rating is capped at 2-stars if the Health Inspection rating is 1-star. No Overall Rating is awarded if the nursing home does not have a Health Inspection Rating (This effectively means that a nursing home is not rated until the home has been operating for more than two years.)

Changes in a nursing homes star rating can be due to the results of a new health inspection report, the processing of new complaints, the aging of older complaints, a new inspection control survey, a revisit, or the resolution of disputes that change the scope and or severity of deficiencies.

Most Recent Nursing Home Inspections

CMS is required to inspect each senior nursing facility at least annually. These inspections take several days. Additional follow-up inspections as conducted as needed or for certain purposes. Inspections stopped for more than seven months in 2020 due to the Covid pandemic. That stoppage has caused all inspections to be delayed as the inspectors continue to deal with a backlog. The table below shows the latest inspections for Legend Oaks Healthcare and Rehabilitation Center - including health, fire, and inspection control inspections:

Inspection Type Inspection Date
Fire Safety Standard March 10, 2021
Fire Safety Standard July 12, 2019
Fire Safety Standard July 26, 2018
Health Complaint October 06, 2021
Health Complaint August 09, 2021
Health Standard March 10, 2021
Health Standard July 12, 2019
Health Standard July 26, 2018
Infection Control February 11, 2022
Infection Control September 22, 2021
Infection Control August 09, 2021
Infection Control January 20, 2021
Infection Control December 02, 2020
Infection Control October 21, 2020
Infection Control October 02, 2020
Infection Control September 18, 2020
Infection Control August 18, 2020
Infection Control July 22, 2020
Infection Control June 04, 2020
Infection Control April 02, 2020

Owner and Operator Information for Legend Oaks Healthcare and Rehabilitation Center -

Our database of owners and operators shows all directo owners of the nursing nurse, any managers and directors, and the most adjacent indirect owners of the facility (that is, if the direct owner is company, then the owners of that company.) Lists of nursing home owners are available and you can search for nursing home owners and operators on our site.

Business Entity Name:

DEWITT MEDICAL DISTRICT

Owners:

Managers and Directors:

Analysis of Nursing Hours Spent Per Patient

CMS provides detailed information about how long nursing staff spends with residents. This data includes nursing subcategories of Registered Nurse, Licensed Practical Nurse, and non-nursing Certified Nursing Assistants. More hours spend per patient should can indicate a better facility or it could indicate more complicated situations.

The nursing staff of Legend Oaks Healthcare and Rehabilitation Center - spends LESS time on average with its residents than the state average and LESS time than the national average for total nursing homes spent per resident.

Type Facility State / National Avg
Registered Nurse (RN)
Hours 0.29 0.38 / 0.67
Case Mix 0.36 0.41 / 0.38
Adjusted 0.31 NA / NA
Licensed Practical Nurse (LPN)
Hours 1.13 1.05 / 0.88
Case Mix 0.75 NA / NA
Adjusted 1.11 NA / NA
Certified Nursing Assistants (CNA)
Hours 1.83 1.98 / 2.22
Case Mix 2.09 NA / NA
Adjusted 1.78 NA / NA
Total Licensed Staff
Hours 1.43 1.43 / 1.55
Physical Therapist (PT)
Hours 0.16 0.06 / 0.07
Total Nursing Homes Spent per Resident on Average
Hours 3.26 3.40 / 3.76
Case Mix 3.20 3.22 / 3.16
Adjusted 3.21 NA / NA

Quality Measures

Quality measures are based both on patient survey information and on the results of actual claims that are filed with CMS. It is not clear what period is covered in the measures.

Desc. Perc. State Avg. / Comparison
Percentage of short-stay residents who were rehospitalized after a nursing home admission (qm521) 16.6% 23.9%
Better
Percentage of short-stay residents who had an outpatient emergency department visit (qm522) 7.0% 11.8%
Better
Number of hospitalizations per 1000 long-stay resident days (qm551) Not Available
Number of outpatient emergency department visits per 1000 long-stay resident days (qm552) Not Available
Percentage of long-stay residents whose need for help with daily activities has increased (qm401) 11.7% 17.0%
Better
Percentage of long-stay residents who lose too much weight (qm404) 1.0% 5.0%
Better
Percentage of low risk long-stay residents who lose control of their bowels or bladder (qm405) 66.3% 51.7%
Worse
Percentage of long-stay residents with a catheter inserted and left in their bladder (qm406) 0.3% 1.5%
Better
Percentage of long-stay residents with a urinary tract infection (qm407) 0.0% 1.4%
Better
Percentage of long-stay residents who have depressive symptoms (qm408) 0.0% 5.0%
Better
Percentage of long-stay residents who were physically restrained (qm409) 0.0% 0.0%
Better
Percentage of long-stay residents experiencing one or more falls with major injury (qm410) 2.8% 3.3%
Better
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (qm415) 100.0% 95.5%
Better
Percentage of long-stay residents who received an antipsychotic medication (qm419) 5.3% 11.1%
Better
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (qm430) 97.7% 82.7%
Better
Percentage of short-stay residents who newly received an antipsychotic medication (qm434) 0.9% 1.9%
Better
Percentage of long-stay residents whose ability to move independently worsened (qm451) 12.4% 15.4%
Better
Percentage of long-stay residents who received an antianxiety or hypnotic medication (qm452) 24.1% 22.2%
Worse
Percentage of high risk long-stay residents with pressure ulcers (qm453) 3.0% 7.7%
Better
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (qm454) 98.3% 96.6%
Better
Percentage of short-stay residents who made improvements in function (qm471) 82.6% 66.9%
Better
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine (qm472) 90.8% 78.2%
Better

Legend Oaks Healthcare and Rehabilitation Center - Violations, Complaints and Fines

These are complaints and fines that are reported by CMS. Some of the data is not very recent, but we have decided to include it here so that you have as much information as possible.

Amount fined in recent period: $31,757.00, Complaints filed: 0

Deficiency Deficiency Date / Date Corrected
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
(Health)
07-26-2018 / 08-24-2018
PASARR screening for Mental disorders or Intellectual Disabilities
(Health)
07-26-2018 / 08-24-2018
Ensure services provided by the nursing facility meet professional standards of quality.
(Health)
07-26-2018 / 08-24-2018
Provide appropriate treatment and care according to orders, resident?s preferences and goals.
(Health)
07-26-2018 / 08-24-2018
Provide safe and appropriate respiratory care for a resident when needed.
(Health)
07-26-2018 / 08-24-2018
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
(Health)
07-26-2018 / 08-24-2018
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
(Health)
07-26-2018 / 08-24-2018
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.
(Health)
07-26-2018 / 08-24-2018
Provide and implement an infection prevention and control program.
(Health)
07-26-2018 / 08-24-2018
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
(Health)
07-26-2018 / 08-24-2018
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
(Fire Safety)
07-26-2018 / 08-28-2018
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
(Fire Safety)
07-26-2018 / 08-28-2018
Ensure each resident receives an accurate assessment.
(Health)
07-12-2019 / 08-08-2019
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
(Health)
07-12-2019 / 08-08-2019
Provide and implement an infection prevention and control program.
(Health)
07-12-2019 / 08-08-2019
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
(Health)
03-10-2021 / 04-02-2021
Provide appropriate treatment and care according to orders, resident?s preferences and goals.
(Health)
03-10-2021 / 04-02-2021
Provide safe and appropriate respiratory care for a resident when needed.
(Health)
03-10-2021 / 04-02-2021
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
(Health)
08-09-2021 / 08-17-2021
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
(Health)
10-06-2021 / 10-07-2021
Provide appropriate treatment and care according to orders, resident?s preferences and goals.
(Health)
10-06-2021 / 10-07-2021
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
(Health)
10-06-2021 / 10-07-2021
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
(Health)
10-06-2021 / 10-07-2021
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
(Health)
10-06-2021 / 10-07-2021
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
(Health)
10-06-2021 / 10-07-2021
Provide and implement an infection prevention and control program.
(Health)
10-06-2021 / 11-10-2021

Hospitals Near Legend Oaks Healthcare and Rehabilitation Center -

Quite often skilled nursing facilities and hospitals work closely together to help patients recover or manage a terminal illness. Hospitals deals with acute care while nursing homes treat patients for a longer period of time. New residents at skilled nursing homes typically come from a hospital and nursing home residents may be readmitted to a hospital if their recovery does not proceed well. (Hospital readmission rates are closely monitored by CMS.) Consequently it is important that you consider which hospitals are near a nursing home which choosing one. Below is a list of hospitals near Legend Oaks Healthcare and Rehabilitation Center -.

Hospital 5-Star Overall Rating
UNIVERSITY HEALTH SYSTEM
4502 MEDICAL DR
SAN ANTONIO, TX 78229
2
CHRISTUS SANTA ROSA MEDICAL CENTER
2827 BABCOCK ROAD
SAN ANTONIO, TX 78229
2
METHODIST HOSPITAL
7700 FLOYD CURL DR
SAN ANTONIO, TX 78229
2
TEXAS VISTA MEDICAL CENTER
7400 BARLITE BLVD
SAN ANTONIO, TX 78224
2
BAPTIST MEDICAL CENTER
111 DALLAS STREET
SAN ANTONIO, TX 78205
3
METHODIST HOSPITAL STONE OAK
1139 E SONTERRA BLVD,
SAN ANTONIO, TX 78258
3
CONNALLY MEMORIAL MEDICAL CENTER
499 10TH STREET
FLORESVILLE, TX 78114
4
Brooke Army Medical Center (FT Sam Houston)
3551 Roger Brooke Drive
Fort Sam Houston, TX 78234
Not Available
METHODIST HOSPITAL AMBULATORY SURGERY
9150 HUEBNER RD SUITE 100
SAN ANTONIO, TX 78240
Not Available
SOUTH TEXAS SPINE AND SURGICAL HOSPITAL
18600 NORTH HARDY OAK BLVD
SAN ANTONIO, TX 78258
Not Available
CHILDREN'S HOSPITAL OF SAN ANTONIO
333 N SANTA ROSA ST
SAN ANTONIO, TX 78207
Not Available
SAN ANTONIO STATE HOSP STATE SCHOOL
6711 S NEW BRAUNFELS AVE
SAN ANTONIO, TX 78223
Not Available
LAUREL RIDGE TREATMENT CENTER
17720 CORPORATE WOODS DRIVE
SAN ANTONIO, TX 78259
Not Available
SAN ANTONIO BEHAVIORAL HEALTHCARE HOSPITAL
8550 HUEBNER ROAD
SAN ANTONIO, TX 78240
Not Available
FOUNDATION SURGICAL HOSPITAL OF SAN ANTONIO
9522 HUEBNER ROAD
SAN ANTONIO, TX 78240
Not Available
BAPTIST EMERGENCY HOSPITAL
16088 SAN PEDRO
SAN ANTONIO, TX 78232
Not Available
LEGENT ORTHOPEDIC + SPINE
5330 NORTH LOOP 1604 WEST
SAN ANTONIO, TX 78249
Not Available
TEXAS CENTER FOR INFECTIOUS DISEASE
2303 SE MILITARY DR P O BOX 23340
SAN ANTONIO, TX 78223
Not Available

Detailed Analysis Pages:

Depending on the nursing home, this page can get really long. So, we have also broken up the data onto separate pages to allow you to find what you want more easily. We will keep adding to these pages as we continue to analyze the nursing home database.

CMS Five Star Ratings and Quality Measures for Legend Oaks Healthcare and Rehabilitation Center -

Five different rating results plus detailed inspection numbers and quality measures for Legend Oaks Healthcare and Rehabilitation Center -.

Covid Infections at Legend Oaks Healthcare and Rehabilitation Center -

This report is updated weekly and shows new and historical infection levels.

Nursing Hours Analysis for Legend Oaks Healthcare and Rehabilitation Center -

How long a nurse spends with a resident can be an important factor in their recovery. This page shows the average nursing hours spent per resident for RNs, LPNs, CNAs, PTs and all licensed staff.

Ownership Details for Legend Oaks Healthcare and Rehabilitation Center -

A list of all of the registered owners for Legend Oaks Healthcare and Rehabilitation Center -. This includes direct and indirect owners and managers.

Noted Deficiencies for Legend Oaks Healthcare and Rehabilitation Center -

A list of all of the deficiencies for the facility. This includes a description, type of deficiency, incident date and when the facility reports that the incident was corrected.

Comparison Ranking of Nearby Skilled Nursing Facilities

How does Legend Oaks Healthcare and Rehabilitation Center - compare to other skilled nursing facilities? This list shows the competitive set within a 25 mile radius.

Best Nursing Homes in SAN ANTONIO, TX

Homes that you should consider. A list ranking the best skilled nursing facilities in SAN ANTONIO based on their weighted inspection score as of October 01, 2022.

Worst Nursing Homes in SAN ANTONIO, TX

Homes that you avoid if possible. A list ranking the worst skilled nursing facilities in SAN ANTONIO based on their weighted inspection score as of October 01, 2022.