Legend Oaks Healthcare and Rehabilitation Center -
Open-data reference.
Legend Oaks Healthcare and Rehabilitation Center - is a for profit - limited liability company facility in Gladewater, TX with 100 certified beds and a 2-star overall CMS rating. The facility has 33 deficiency records on file. Total penalties: $125K.
1201 FM 2685, Gladewater, TX 75647
Phone: 9038452175
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 676048
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 100
- Residents
- 69
- In Hospital
- No
- County
- Gregg
- Last Inspection
- Feb 12, 2025
Staffing Data
- RN Hours
- 0.66 (nat'l avg: 0.68)
- LPN Hours
- 0.93
- CNA Hours
- 1.50
- Total Nursing Hours
- 3.09 (nat'l avg: 3.89)
- PT Hours
- 0.25
- Nursing Turnover
- 50.8%
- RN Turnover
- 41.7%
What the CMS Record Reveals About Legend Oaks Healthcare and Rehabilitation Center -
Legend Oaks Healthcare and Rehabilitation Center - operates 100 certified beds in Gladewater, TX with approximately 69 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (3★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 33 deficiency records from recent surveys, of which 9 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 6 penalties totaling $125K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.09 total nursing hours per resident day (national average 3.89), with RN coverage at 0.66 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, Legend Oaks Healthcare and Rehabilitation Center - falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 50.8%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (33 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 14, 2025
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 14, 2025
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 14, 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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 14, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 14, 2025
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Mar 14, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 30, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 30, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 30, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 30, 2024
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Jul 16, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 16, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 21, 2024
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Mar 21, 2024
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Category: Resident Rights Deficiencies
Corrected: Mar 21, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 23, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Feb 23, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 23, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Feb 23, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 23, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 23, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 23, 2024
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 23, 2024
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Feb 23, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 12, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Oct 12, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 6, 2022
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 6, 2022
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.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 6, 2022
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 6, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 6, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 6, 2022
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Dec 6, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 30.4% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 3.2% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.5% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 4.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.8% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 99.5% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 92.2% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 2.8% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 22.1% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 28.4% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 88.0% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.3% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 13.9% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 2.5% | Yes |
Penalty History 6 penalties totaling $125K
| Date | Type | Amount |
|---|---|---|
| Oct 23, 2024 | Fine | $17K |
| Oct 23, 2024 | Fine | $17K |
| Oct 23, 2024 | Fine | $17K |
| Oct 23, 2024 | Fine | $17K |
| Jun 19, 2024 | Fine | $43K |
| Sep 13, 2023 | Fine | $14K |
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Frequently Asked Questions
What is the overall CMS rating for Legend Oaks Healthcare and Rehabilitation Center -?
What are the staffing levels at Legend Oaks Healthcare and Rehabilitation Center -?
How many beds does Legend Oaks Healthcare and Rehabilitation Center - have?
Does Legend Oaks Healthcare and Rehabilitation Center - have any deficiencies on record?
Has Legend Oaks Healthcare and Rehabilitation Center - received any fines or penalties?
Who owns Legend Oaks Healthcare and Rehabilitation Center -?
When was Legend Oaks Healthcare and Rehabilitation Center - last inspected?
What quality measures are tracked for Legend Oaks Healthcare and Rehabilitation Center -?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.