Public Record
Legend Oaks Healthcare and Rehabilitation Center -
Operated by The Ensign Group
From CMS
Facility profile
- CMS overall rating
- 2 / 5
- Certified beds
- 100
- Avg. residents per day
- 73.6
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Health citations
- 35
- Fire safety findings
- 3
- Inspections on file
- 12
- Last inspection
- 2026-01-29
*CMS
*CMS
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*CMS
Citations
35 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0802Generalpotential for harm
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0761Generalpotential for harm
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.
- 0807Generalpotential for harm
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
- 0610Seriousimmediate jeopardy
Respond appropriately to all alleged violations.
- 0600Seriousimmediate jeopardy
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0609Seriousimmediate jeopardy
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0607Seriousimmediate jeopardy
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0925Seriousactual harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0563Generalpotential for harm
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
- 0603Seriousactual harm
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0758Generalpotential for harm
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.
- 0761Generalpotential for harm
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.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0742Generalpotential for harm
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.
- 0697Seriousimmediate jeopardy
Provide safe, appropriate pain management for a resident who requires such services.
- 0686Seriousimmediate jeopardy
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- Inspection1 deficiency
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview…
Read full statement of deficiencies - Inspection1 deficiency
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on…
Read full statement of deficiencies - Inspection6 deficiencies
F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents…
Read full statement of deficiencies - View inspection reportInspectionFire Safety1 deficiency
- Inspection4 deficiencies
F 0600 Level of Harm - Immediate jeopardy to resident health or safety Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation…
Read full statement of deficiencies - Inspection2 deficiencies
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility…
Read full statement of deficiencies - Inspection3 deficiencies
F 0563 Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility did not ensure the right to receive visitors of his or her choosing at the…
Read full statement of deficiencies - Inspection9 deficiencies
F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had…
Read full statement of deficiencies - View inspection reportInspectionFire Safety1 deficiency
- Inspection2 deficiencies
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based…
Read full statement of deficiencies
Showing the 10 most recent inspections. 2 earlier inspections are also on record.
Ownership
The Ensign Group
338nursing homes nationwide, in CMS records
FAQ
Questions and answers
- What is Legend Oaks Healthcare and Rehabilitation Center -?
- Legend Oaks Healthcare and Rehabilitation Center - is a Medicare- and Medicaid-certified nursing home in Gladewater, TX, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 676048.
- What is the CMS rating for Legend Oaks Healthcare and Rehabilitation Center -?
- Legend Oaks Healthcare and Rehabilitation Center - has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Legend Oaks Healthcare and Rehabilitation Center - have?
- Legend Oaks Healthcare and Rehabilitation Center - is certified for 100 beds. It serves an average of 73.6 residents per day.
- How many citations does Legend Oaks Healthcare and Rehabilitation Center - have?
- Legend Oaks Healthcare and Rehabilitation Center - has 35 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Legend Oaks Healthcare and Rehabilitation Center - last inspected?
- Legend Oaks Healthcare and Rehabilitation Center - was last inspected on January 29, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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