Federal inspection record · CMS data as of October 1, 2026
Legend Oaks Healthcare And Rehabilitation Center G
1201 Fm 2685, Gladewater, TX · (903) 845-2175
- Certified beds
- 100
- Residents per day
- 73
- Ownership
- Government
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- December 1, 2004
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Texas homes
Legend Oaks Healthcare And Rehabilitation Center G carries 99 inspection points. That is fewer than 36% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
37 health citations on record since 2024. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (6)
-
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
J
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
-
J
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
-
J
Respond appropriately to all alleged violations.
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G
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
-
H
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Everything else, by area of care
Quality of Life and Care8E
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- E
Provide activities to meet all resident's needs.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Resident Rights7E
- E
Give residents a notice of rights, rules, services and charges.
- E
Ensure residents have reasonable access to and privacy in their use of communication methods.
- E
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.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
- E
Reasonably accommodate the needs and preferences of each resident.
- D
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
- D
Reasonably accommodate the needs and preferences of each resident.
Pharmacy Service6E
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
- E
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.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- E
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.
- D
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.
Infection Control3E
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation2D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Nutrition and Dietary2D
- D
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- D
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Resident Assessment and Care Planning2E
- E
Ensure each resident receives an accurate assessment.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Nursing and Physician Services1C
- C
Post nurse staffing information every day.
Inspection history
2026-04-15
13 health deficiencies · 1 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2025-02-12
10 health deficiencies · 1 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
2024-01-24
14 health deficiencies · 1 fire-safety deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 10 min of nursing staff time a day, 22 min of it from a registered nurse.
This home
3 h 10 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 47% of nursing staff and 50% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$110,274 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2024-10-23 | Fine | $16,801 |
| 2024-10-23 | Fine | $16,801 |
| 2024-10-23 | Fine | $16,801 |
| 2024-10-23 | Fine | $16,801 |
| 2024-06-19 | Fine | $43,070 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.7 pts worse | 2.7 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.3 pts better | 0.7 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine2.7 pts better | 99.1% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine1.5 pts worse | 95.5% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.1 pts worse | 4.3% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms0.3 pts better | 2.0% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.4 pts better | 1.5% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication8.7 pts worse | 26.5% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication6.7 pts better | 3.1% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened6.2 pts worse | 19.1% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased7.8 pts worse | 23.6% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.8 pts better | 0.0% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinenceAbout the same | 12.5% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.6 pts better | 1.1% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine1.5 pts better | 90.2% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit1.2 pts better | 11.0% | 12.2% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.6 pts better | 0.8% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine6.4 pts worse | 79.0% | 85.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission14.2 pts worse | 39.7% | 25.5% | 23.4% |
·
Who owns and runs it
15 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Fannin County Hospital Authority | 5% Or Greater Direct Ownership Interest · Organization | 100% | 54 facilities |
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| Daffodil Healthcare, Inc. | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Daffodil Healthcare, Inc. | Adp Of The SNF · Organization | 0% | 1 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Kegarise, Brandon | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| Kegarise, Brandon | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Kegarise, Brandon | Adp Of The SNF · Individual | 0% | 2 facilities |
| National Health Investors, Inc. | Adp Of The SNF · Organization | 0% | 31 facilities |
| Sanderson, Clark | Corporate Officer · Individual | 0% | 58 facilities |
| Shen, Hong-I | Managing Control - Governing Body · Individual | 0% | 5 facilities |
| Shen, Hong-I | Operational/Managerial Control · Individual | 0% | 5 facilities |
| Shen, Hong-I | Adp Of The SNF · Individual | 0% | 5 facilities |
| Texas Nhi Investors, LLC | Adp Of The SNF · Organization | 0% | 19 facilities |
·
Fire safety
3 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Services3C
- B
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- B
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
·
Other homes nearby
-
Truman W Smith Children's Care Center
Gladewater, TX
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 4 h 42 min
- Fines
- $0
-
Pine Tree Lodge Nursing Center
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★★★★★- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 3 h 6 min
- Fines
- $232,525
-
Focused Care of Gilmer
Gilmer, TX · Focused Post Acute Care Partners
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 2 h 54 min
- Fines
- $15,288