Legend Oaks Healthcare and Rehabilitation Center -

1201 FM 2685, Gladewater, TX 75647 · CCN 676048 · 100 certified beds · Data as of 2026-07-01

CMS overall2 of 5CMS inspections2 of 5CMS staffing2 of 5CMS quality3 of 5

Star ratings are issued by CMS (the federal Centers for Medicare & Medicaid Services), not by NursingHomeLens. We report them; we do not rate or rank facilities.

State inspectors recorded 4 immediate-jeopardy citation(s) here in the last three years — CMS's most serious level.

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Serious inspection findings

2024-10-23 — IMMEDIATE JEOPARDY (tag F0609, severity J)

Freedom from Abuse, Neglect, and Exploitation Deficiencies · correction not recorded in CMS data

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

2024-10-23 — IMMEDIATE JEOPARDY (tag F0610, severity J)

Freedom from Abuse, Neglect, and Exploitation Deficiencies · correction not recorded in CMS data

Respond appropriately to all alleged violations.

2024-10-23 — IMMEDIATE JEOPARDY (tag F0600, severity J)

Freedom from Abuse, Neglect, and Exploitation Deficiencies · correction not recorded in CMS data

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

2024-10-23 — IMMEDIATE JEOPARDY (tag F0607, severity J)

Freedom from Abuse, Neglect, and Exploitation Deficiencies · correction not recorded in CMS data

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

2024-06-19 — ACTUAL HARM (tag F0925, severity G)

Environmental Deficiencies · correction not recorded in CMS data

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

2024-02-22 — ACTUAL HARM (tag F0603, severity H)

Freedom from Abuse, Neglect, and Exploitation Deficiencies · correction not recorded in CMS data

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

2023-09-13 — IMMEDIATE JEOPARDY (tag F0689, severity J)

Quality of Life and Care Deficiencies · correction not recorded in CMS data

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

Staffing, from payroll records

Nursing hours / resident / day

2.69

state median 2.67

Weekend staffing gap

−7%

fewer nursing hours on weekends · state median −7%

RN hours / resident / day

0.19

registered nurses only

Contract (agency) staff

1%

share of all nursing hours

Days with zero RN hours reported

17

with residents present

Nursing staff turnover

43%

per year, per CMS

Source: CMS Payroll-Based Journal, 2026Q1, 90 reported days — actual payroll data, not the facility's own estimates.

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Penalties and enforcement

3 enforcement action(s), totaling $74,156 in fines.

Date	Type	Amount
2024-10-23	Fine	$16,801
2024-06-19	Fine	$43,070
2023-09-13	Fine	$14,285

Ownership

Ownership type: Government - Hospital district. Part of the THE ENSIGN GROUP chain.

Other facilities under the same ownership, with their CMS overall ratings:

THE HEALTHCARE CENTER OF EASTVIEW (BIRMINGHAM, AL) — CMS overall2 of 5
Polaris Extended Care (ANCHORAGE, AK) — CMS overall2 of 5
THE HEALTH CENTER AT RESEARCH PARK (HUNTSVILLE, AL) — CMS overall1 of 5
POLARIS TRANSITIONAL CARE (ANCHORAGE, AK) — CMS overall3 of 5
Desert Terrace Healthcare Center (PHOENIX, AZ) — CMS overall3 of 5
PUEBLO SPRINGS REHABILITATION CENTER (TUCSON, AZ) — CMS overall2 of 5
CASAS ADOBES POST ACUTE REHAB CENTER (TUCSON, AZ) — CMS overall3 of 5
MISSION PALMS POST ACUTE (MESA, AZ) — CMS overall5 of 5

Full citation history

By severity: No harm, potential for minimal harm: 2 · Actual harm: 2 · Potential for more than minimal harm: 30 · Immediate jeopardy: 5

Survey date	Tag	Category	Severity	Corrected
2026-05-23	F0686	Quality of Life and Care Deficiencies	D	not recorded
2026-04-15	F0572	Resident Rights Deficiencies	E	not recorded
2026-04-15	F0576	Resident Rights Deficiencies	E	not recorded
2026-04-15	F0577	Resident Rights Deficiencies	C	not recorded
2026-04-15	F0585	Resident Rights Deficiencies	E	not recorded
2026-04-15	F0679	Quality of Life and Care Deficiencies	E	not recorded
2026-04-15	F0690	Quality of Life and Care Deficiencies	D	not recorded
2026-04-15	F0732	Nursing and Physician Services Deficiencies	C	not recorded
2026-04-15	F0755	Pharmacy Service Deficiencies	E	not recorded
2026-04-15	F0761	Pharmacy Service Deficiencies	D	not recorded
2026-04-15	F0880	Infection Control Deficiencies	D	not recorded
2026-01-29	F0609	Freedom from Abuse, Neglect, and Exploitation Deficiencies	D	not recorded
2026-01-21	F0689	Quality of Life and Care Deficiencies	D	not recorded
2025-02-12	F0558	Resident Rights Deficiencies	E	not recorded
2025-02-12	F0695	Quality of Life and Care Deficiencies	D	not recorded
2025-02-12	F0761	Pharmacy Service Deficiencies	E	not recorded
2025-02-12	F0802	Nutrition and Dietary Deficiencies	D	not recorded
2025-02-12	F0807	Nutrition and Dietary Deficiencies	D	not recorded
2025-02-12	F0880	Infection Control Deficiencies	E	not recorded
2024-10-23	F0600	Freedom from Abuse, Neglect, and Exploitation Deficiencies	J	not recorded
2024-10-23	F0607	Freedom from Abuse, Neglect, and Exploitation Deficiencies	J	not recorded
2024-10-23	F0609	Freedom from Abuse, Neglect, and Exploitation Deficiencies	J	not recorded
2024-10-23	F0610	Freedom from Abuse, Neglect, and Exploitation Deficiencies	J	not recorded
2024-06-19	F0684	Quality of Life and Care Deficiencies	D	not recorded
2024-06-19	F0925	Environmental Deficiencies	G	not recorded
2024-02-22	F0563	Resident Rights Deficiencies	D	not recorded
2024-02-22	F0603	Freedom from Abuse, Neglect, and Exploitation Deficiencies	H	not recorded
2024-02-22	F0880	Infection Control Deficiencies	E	not recorded
2024-01-24	F0558	Resident Rights Deficiencies	D	not recorded
2024-01-24	F0607	Freedom from Abuse, Neglect, and Exploitation Deficiencies	D	not recorded
2024-01-24	F0641	Resident Assessment and Care Planning Deficiencies	E	not recorded
2024-01-24	F0657	Resident Assessment and Care Planning Deficiencies	D	not recorded
2024-01-24	F0689	Quality of Life and Care Deficiencies	D	not recorded
2024-01-24	F0695	Quality of Life and Care Deficiencies	E	not recorded
2024-01-24	F0757	Pharmacy Service Deficiencies	E	not recorded
2024-01-24	F0758	Pharmacy Service Deficiencies	D	not recorded
2024-01-24	F0761	Pharmacy Service Deficiencies	E	not recorded
2023-09-13	F0600	Freedom from Abuse, Neglect, and Exploitation Deficiencies	D	not recorded
2023-09-13	F0689	Quality of Life and Care Deficiencies	J	not recorded

Sources: CMS Provider Information, Health Deficiencies, Penalties, and Ownership datasets (data.cms.gov/provider-data), processed 2026-07-01; CMS Payroll-Based Journal daily staffing. Find this facility on Care Compare: search “Legend Oaks Healthcare and Rehabilitation Center -, Gladewater” at medicare.gov/care-compare.