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)
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
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
69
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
Staffing
Hours and turnover
RN hours / resident day
0.66
Registered nurse staffing
LPN hours / resident day
0.93
Licensed practical nurse staffing
Aide hours / resident day
1.50
Nurse aide staffing
Weekend hours
2.64
Weekend nurse staffing
RN turnover
42%
Annual RN turnover
Total nurse turnover
51%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
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
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 2024-02-23
D · Potential for more than minimal harm
2024-01-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-24
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 2024-02-23
D · Potential for more than minimal harm
2024-01-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-02-23
J · Immediate jeopardy
2023-09-13
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 2023-10-12
D · Potential for more than minimal harm
2023-09-13
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 2023-10-12
J · Immediate jeopardy
2022-11-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-06
J · Immediate jeopardy
2022-11-08
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-12-06
D · Potential for more than minimal harm
2022-11-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-12-06
D · Potential for more than minimal harm
2022-11-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-06
D · Potential for more than minimal harm
2022-11-08
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2022-12-06
D · Potential for more than minimal harm
2022-11-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-12-06
D · Potential for more than minimal harm
2022-11-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-06
Penalties and ownership
What sits behind the stars
$16,801
2024-10-23
Fine
Fine · fine $16,801
Fine
$16,801
2024-10-23
Fine
Fine · fine $16,801
Fine
$16,801
2024-10-23
Fine
Fine · fine $16,801
Fine
$16,801
2024-10-23
Fine
Fine · fine $16,801
Fine
$43,070
2024-06-19
Fine
Fine · fine $43,070
Fine
$14,285
2023-09-13
Fine
Fine · fine $14,285
Fine
Ownership
Fannin County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Daffodil Healthcare, Inc.
Operational/Managerial Control · Organization
Keetch, Chad
Corporate Officer · Individual
Kegarise, Brandon
Operational/Managerial Control · Individual
Sanderson, Clark
Corporate Officer · Individual
Shen, Hong-I
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Truman W Smith Children's Care Center
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5-star overall rating with 5-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Pine Tree Lodge Nursing Center
Longview, TX
2-star overall rating with 2-star inspections with $225,502 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Focused Care of Gilmer
Gilmer, TX
2-star overall rating with 2-star inspections with $240,635 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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