Gladewater, TX

Legend Oaks Healthcare and Rehabilitation Center -

2-star overall rating with 2-star inspections with $124,559 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

1201 Fm 2685, Gladewater, TX

(903) 845-2175

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

100

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

2004-12-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

329 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.66

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.93

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.50

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.09

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.59

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.64

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.31

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.25

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.79

CMS adjusted RN staffing hours

Adjusted total hours

3.68

CMS adjusted total nurse staffing hours

Case-mix index

1.15

Higher values indicate more complex resident acuity

RN turnover

42%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,064

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

21.54

Composite VBP score used to determine payment impact.

Payment multiplier

0.9826

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.12

Baseline 22.21% · Performance 21.89% · Measure score 0.12 · Achievement 0 · Improvement 0.12

Healthcare-associated infections

5.29

Baseline 8.80% · Performance 6.60% · Measure score 5.29 · Achievement 4.14 · Improvement 5.29

Total nurse turnover

1.99

Baseline 60.42% · Performance 55.56% · Measure score 1.99 · Achievement 1.99 · Improvement 0.87

Adjusted total nurse staffing

1.22

Baseline 3.26 hours · Performance 3.43 hours · Measure score 1.22 · Achievement 1.22 · Improvement 0.17

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.83%	10.72% 0.1 pts worse	No Different than the National Rate · Eligible stays 118 · Observed rate 13.56% · Lower 95% interval 8.05%
Discharge to community	48.37%	50.57% 2.2 pts worse	No Different than the National Rate · Eligible stays 87 · Observed rate 44.83% · Lower 95% interval 38.88%
Medicare spending per beneficiary	1.15	1.02 0.1 pts worse
Drug regimen review with follow-up	96.83%	95.27% 1.6 pts better	Numerator 61 · Denominator 63
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 63
Discharge self-care score	40%	53.69% 13.7 pts worse	Numerator 18 · Denominator 45
Discharge mobility score	42.22%	50.94% 8.7 pts worse	Numerator 19 · Denominator 45
Pressure ulcers or injuries, new or worsened	3.17%	2.29% 0.9 pts worse	Numerator 2 · Denominator 63 · Adjusted rate 2.52%
Healthcare-associated infections requiring hospitalization	6.6%	7.12% 0.5 pts better	No Different than the National Rate · Eligible stays 69 · Observed rate 5.8% · Lower 95% interval 3.84%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 114
Staff flu vaccination coverage	18.06%	42% 23.9 pts worse	Numerator 26 · Denominator 144
Discharge function score	51.11%	56.45% 5.3 pts worse	Numerator 23 · Denominator 45
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	4.17%	25.2% 21 pts worse	Numerator 1 · Denominator 24

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.8	2.1 0.3 pts better	1.9 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.9	2.1 0.2 pts better	1.8 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.5%	97.1% 2.4 pts better	93.4% 6.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.8%	3.3% 0.5 pts better	3.3% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.0% · Q3 3.6% · Q4 1.9% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	4.0%	2.7% 1.3 pts worse	11.4% 7.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.5% · Q3 7.5% · Q4 2.0% · 4Q avg 4.0%
Percentage of long-stay residents who lose too much weight	3.2%	3.3% 0.1 pts better	5.4% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.3% · Q3 4.1% · Q4 2.2% · 4Q avg 3.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.4%	18.9% 9.5 pts worse	19.6% 8.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 31.2% · Q3 28.0% · Q4 25.5% · 4Q avg 28.4%
Percentage of long-stay residents who received an antipsychotic medication	2.5%	10.8% 8.3 pts better	16.7% 14.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.5% · Q3 2.3% · Q4 2.6% · 4Q avg 2.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	22.1%	15.4% 6.7 pts worse	16.3% 5.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 12.5% · Q3 27.6% · Q4 23.7% · 4Q avg 22.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	30.4%	16.1% 14.3 pts worse	14.9% 15.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 29.5% · Q3 31.2% · Q4 34.8% · 4Q avg 30.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.5%	0.8% 0.3 pts better	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	13.9%	15.0% 1.1 pts better	19.8% 5.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 14.0% · Q3 14.2% · Q4 8.6% · 4Q avg 13.9%
Percentage of long-stay residents with pressure ulcers	2.3%	4.2% 1.9 pts better	5.1% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.3% · Q3 2.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	92.2%	89.7% 2.5 pts better	81.7% 10.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 93.0% · Q3 87.8% · Q4 89.8% · 4Q avg 92.2%
Percentage of short-stay residents who had an outpatient emergency department visit	10.4%	12.0% 1.6 pts better	12.0% 1.6 pts better	Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 10.6% · Expected 11.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.8%	1.5% 1.3 pts worse	1.6% 1.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.5% · Q4 3.5% · 4Q avg 2.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	88.0%	88.0% About the same	79.7% 8.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	33.2%	25.9% 7.3 pts worse	23.9% 9.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 33.2% · Observed 29.8% · Expected 21.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-12 · Fire 2025-02-12

8 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2024-01-24 · Fire 2024-01-24

15 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 3 Health 2022-11-08 · Fire 2022-11-08

12 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Fire safety

Fire-safety citations

C · Minimal harm 2025-02-12

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

B · Minimal harm 2024-01-24

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

B · Minimal harm 2022-11-08

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-29

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Not marked corrected

D · Potential for more than minimal harm 2026-01-21

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2026-02-04

E · Potential for more than minimal harm 2025-02-12

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-02-12

F761 · Pharmacy Service Deficiencies

Health

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 2025-03-14

E · Potential for more than minimal harm 2025-02-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-02-12

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-02-12

F802 · Nutrition and Dietary Deficiencies

Health

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-02-12

F807 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Corrected 2025-03-14

J · Immediate jeopardy 2024-10-23

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-08-30

J · Immediate jeopardy 2024-10-23

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-08-30

J · Immediate jeopardy 2024-10-23

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-08-30

J · Immediate jeopardy 2024-10-23

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-08-30

G · Actual harm 2024-06-19

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2024-07-16

D · Potential for more than minimal harm 2024-06-19

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-07-16

H · Actual harm 2024-02-22

F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Corrected 2024-03-21

E · Potential for more than minimal harm 2024-02-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-03-21

D · Potential for more than minimal harm 2024-02-22

F563 · Resident Rights Deficiencies

Health

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Corrected 2024-03-21

E · Potential for more than minimal harm 2024-01-24

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-02-23

E · Potential for more than minimal harm 2024-01-24

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-02-23

E · Potential for more than minimal harm 2024-01-24

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-02-23

E · Potential for more than minimal harm 2024-01-24