Legend Oaks Healthcare and Rehabilitation Center -
1201 Fm 2685 · Gladewater, TX · 75647 · 9038452175
100 certified beds Government - Hospital district Chain: The Ensign Group
Why this verdict
- Federal penalties on record: $67,204 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
5 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
5 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$67,204 in federal fines in the last 24 months
4 fines — CMS fines are reserved for verified, serious non-compliance.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.15 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.40 | 0.55–0.75 |
| Weekend hours / resident-day | 2.63 | ≈ weekday level |
| Nursing turnover / year | 40% | median 45% |
| Fines (3-yr window) | 6 · $124,559 |
Inspection citations (38 in the current record)
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Potential for harm · E April 15, 2026
Give residents a notice of rights, rules, services and charges.
Corrected May 1, 2026 · Resident Rights
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Potential for harm · E April 15, 2026
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected May 1, 2026 · Resident Rights
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Potential for harm · E April 15, 2026
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected May 1, 2026 · Resident Rights
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Potential for harm · E April 15, 2026
Provide activities to meet all resident's needs.
Corrected May 1, 2026 · Quality of Life and Care
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Potential for harm · D April 15, 2026
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected May 1, 2026 · Quality of Life and Care
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Potential for harm · E April 15, 2026
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 24, 2026 · Pharmacy Service
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Potential for harm · D April 15, 2026
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.
Corrected May 1, 2026 · Pharmacy Service
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Potential for harm · D April 15, 2026
Provide and implement an infection prevention and control program.
Corrected May 1, 2026 · Infection Control
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No harm found · C April 15, 2026
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected April 16, 2026 · Resident Rights
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No harm found · C April 15, 2026
Post nurse staffing information every day.
Corrected May 1, 2026 · Nursing and Physician Services
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Potential for harm · D January 29, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 18, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 21, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected February 4, 2026 · Quality of Life and Care
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Potential for harm · E February 12, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected March 14, 2025 · Resident Rights
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Potential for harm · D February 12, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected March 14, 2025 · Quality of Life and Care
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Potential for harm · E February 12, 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.
Corrected March 14, 2025 · Pharmacy Service
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Potential for harm · D February 12, 2025
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected March 14, 2025 · Nutrition and Dietary
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Potential for harm · D February 12, 2025
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected March 14, 2025 · Nutrition and Dietary
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Potential for harm · E February 12, 2025
Provide and implement an infection prevention and control program.
Corrected March 14, 2025 · Infection Control
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Immediate jeopardy · J October 23, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 30, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · J October 23, 2024 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected August 30, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · J October 23, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected August 30, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · J October 23, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected August 30, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G June 19, 2024 · found via complaint
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected July 16, 2024 · Environmental
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Potential for harm · D June 19, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 16, 2024 · Quality of Life and Care
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Actual harm · H February 22, 2024 · found via complaint
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected March 21, 2024 · Freedom from Abuse, Neglect, and Exploitation
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 23, 2024 | Fine | $16,801 |
| October 23, 2024 | Fine | $16,801 |
| October 23, 2024 | Fine | $16,801 |
| October 23, 2024 | Fine | $16,801 |
| June 19, 2024 | Fine | $43,070 |
| September 13, 2023 | Fine | $14,285 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 676048 · certified since December 1, 2004. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.