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Nursing home report card · Gladewater, TX

Legend Oaks Healthcare and Rehabilitation Center G

1201 FM 2685, Gladewater, TX 75647

Call this home: (903) 845-2175

View this home on Medicare.gov ↗

Infection-control problems noted

Quick summary

Below-average Medicare rating

Overall rating is 2 of 5 stars. Its health-inspection rating is 2 of 5. Read the dated inspection findings and separate staffing and care ratings below.

Our summary of public Medicare records. It does not establish that this home harmed a particular resident. About this summary.

How recent is this information?
Medicare file prepared
Aug 1, 2026
Our record last updated
Oct 15, 2026
Last routine health inspection
Apr 15, 2026

These dates mean different things. A new file can include older inspections and staffing figures. Read about the dates.

Medicare ratings

One star is the lowest rating. Five stars is the highest. Ratings are a starting point—read the inspection findings too.

Overall rating
2out of 5

Combines inspection, staffing, and care measures.

Below-average Medicare rating

Health inspections
2out of 5

Based on problems found during health inspections.

Below-average Medicare rating

Nursing staff
2out of 5

Based on staffing levels and related measures.

Below-average Medicare rating

Health and care results
3out of 5

Based on reported health and care results.

About average for U.S. nursing homes

What do the ratings and warnings mean?
Medicare ratings
One star is the lowest rating. Five stars is the highest. These are government ratings, not family reviews.
Inspection problems
Inspectors found that a home did not meet a care or safety rule. The official term is “deficiency.”
Abuse warning
Medicare has flagged the home because of abuse-related inspection findings. Read the findings and dates.
Nursing staff time
Average staff hours for each resident per day. This does not mean each resident gets that much one-to-one care.

Learn about the records and their limits →

At a glance

These numbers come from the records we have. Inspection problems are rules the home did not meet. The dates covered can differ.

Care and safety problems
39

Care, safety, and resident-rights issues on recent inspections

Fire-safety problems
0

Building, alarms, exits, and related safety citations

Reported fines
$124,559

Total fine amounts in the imported penalty records

Medicare file prepared
Aug 1, 2026

Medicare home ID: 676048

Inspection findings to read first

Start with these past findings. We show the most serious first, then the most recent. They do not describe the home’s condition today.

  • Immediate danger to residents · isolated case

    Oct 23, 2024 · Inspection rule 0609

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

  • Immediate danger to residents · isolated case

    Oct 23, 2024 · Inspection rule 0610

    Respond appropriately to all alleged violations.

  • Immediate danger to residents · isolated case

    Oct 23, 2024 · Inspection rule 0607

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

Read the inspection history →

Nursing staff time

These are average staff hours for each resident per day. They are not one-to-one bedside care. The file does not give the reporting period for each figure.

Registered nurses (RNs)
0.37hours per resident per day

about 22 minutes per resident per day

All nursing staff
3.11hours per resident per day

about 3 hr 6 min per resident per day

Registered nurse time on weekends
0.16hours per resident per day

about 10 minutes per resident per day

Latest inspection summary

A summary of the most recent routine inspections. You can open the dated findings below.

We do not have a routine inspection summary for this home. Check the dated findings below and the Medicare.gov record.

How this home compares

Compared with state and national averages. The numbers may cover different periods.

  • Overall CMS rating: 2 stars
  • Health inspection rating: 2 stars
  • Staffing rating: 2 stars
  • Registered nurse time per resident: 0.37 hours/day
  • Total nurse time per resident: 3.11 hours/day
See the dates used for these averages

Medicare file dates: this home Aug 1, 2026; Texas averages Unavailable; U.S. averages Oct 1, 2026.

Other concerns in the records

These points may be worth asking about. They do not establish what happened to a particular resident. See our Terms of Use.

  • Overall star rating is 2 or lower
  • Health inspection rating is 2 stars or lower
  • Recent citations include infection-control problems
  • Inspectors have listed an unusually high number of problems
  • CMS has fined this home in the recent reporting period

How serious were the problems?

Inspectors rate each problem by how much harm it caused or could cause. We group the CMS letter codes into plain language.

  • Immediate danger to residents5 citations
  • Caused actual harm2 citations
  • Could have caused harm30 citations
  • Low risk of harm2 citations

Why inspectors showed up

Routine checks happen on a schedule. Complaint visits happen when someone reports a concern.

Complaints
0
Routine
39
Fire safety
0
Other
0

Who owns it

Names CMS lists as owners or managers · reported as Government - Hospital district.

  • We do not have individual owner names for this home.

Other homes in this group: All The Ensign Group nursing homes

Inspection history

Open a date to read what inspectors found. The harm labels explain how serious the problem was at the time.

May 23, 20261 finding
  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0686 · code D

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

April 15, 202610 findings
  • Resident Rights problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0572 · code E

    Give residents a notice of rights, rules, services and charges.

  • Resident Rights problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0576 · code E

    Ensure residents have reasonable access to and privacy in their use of communication methods.

  • Resident Rights problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0585 · code 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.

  • Quality of Life and Care problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0679 · code E

    Provide activities to meet all resident's needs.

  • Pharmacy Service problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0755 · code E

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0690 · code 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.

  • Pharmacy Service problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0761 · code 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.

  • Infection Control problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0880 · code D

    Provide and implement an infection prevention and control program.

  • Resident Rights problems
    Low risk of harm · widespread case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0577 · code C

    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  • Nursing and Physician Services problems
    Low risk of harm · widespread case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0732 · code C

    Post nurse staffing information every day.

January 29, 20261 finding
  • Freedom from Abuse, Neglect, and Exploitation problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0609 · code D

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

January 21, 20261 finding
  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0689 · code D

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

February 12, 20256 findings
  • Resident Rights problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0558 · code E

    Reasonably accommodate the needs and preferences of each resident.

  • Pharmacy Service problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0761 · code 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.

  • Infection Control problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0880 · code E

    Provide and implement an infection prevention and control program.

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0695 · code D

    Provide safe and appropriate respiratory care for a resident when needed.

  • Nutrition and Dietary problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0802 · code D

    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

  • Nutrition and Dietary problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0807 · code D

    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

October 23, 20244 findings
  • Freedom from Abuse, Neglect, and Exploitation problems
    Immediate danger to residents · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0600 · code J

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

  • Freedom from Abuse, Neglect, and Exploitation problems
    Immediate danger to residents · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0607 · code J

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

  • Freedom from Abuse, Neglect, and Exploitation problems
    Immediate danger to residents · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0609 · code J

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

  • Freedom from Abuse, Neglect, and Exploitation problems
    Immediate danger to residents · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0610 · code J

    Respond appropriately to all alleged violations.

June 19, 20242 findings
  • Environmental problems
    Caused actual harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0925 · code G

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

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0684 · code D

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

February 22, 20243 findings
  • Freedom from Abuse, Neglect, and Exploitation problems
    Caused actual harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0603 · code H

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

  • Infection Control problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0880 · code E

    Provide and implement an infection prevention and control program.

  • Resident Rights problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0563 · code D

    Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

January 24, 20249 findings
  • Resident Assessment and Care Planning problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0641 · code E

    Ensure each resident receives an accurate assessment.

  • Quality of Life and Care problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0695 · code E

    Provide safe and appropriate respiratory care for a resident when needed.

  • Pharmacy Service problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0757 · code E

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • Pharmacy Service problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0761 · code 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.

  • Resident Rights problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0558 · code D

    Reasonably accommodate the needs and preferences of each resident.

  • Freedom from Abuse, Neglect, and Exploitation problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0607 · code D

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

  • Resident Assessment and Care Planning problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0657 · code D

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0689 · code D

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

  • Pharmacy Service problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0758 · code 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…

September 13, 20232 findings
  • Quality of Life and Care problems
    Immediate danger to residents · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0689 · code J

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

  • Freedom from Abuse, Neglect, and Exploitation problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0600 · code D

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

Fines & penalties

These fines appear in Medicare’s records. A listed amount does not tell us whether it has been paid.

  • Fine · Oct 23, 2024$16,801
  • Fine · Oct 23, 2024$16,801
  • Fine · Oct 23, 2024$16,801
  • Fine · Oct 23, 2024$16,801
  • Fine · Jun 19, 2024$43,070
  • Fine · Sep 13, 2023$14,285

Other homes in this chain

The Ensign Group · other locations in Texas

Related topics

Questions about Legend Oaks Healthcare and Rehabilitation Center G

What is Legend Oaks Healthcare and Rehabilitation Center G's Medicare star rating?
As of August 1, 2026, Legend Oaks Healthcare and Rehabilitation Center G in Gladewater, Texas has an overall CMS rating of 2 out of 5 stars. Other CMS scores: health inspection 2 of 5, staffing 2 of 5, quality measures 3 of 5. These are CMS ratings based on inspection, staffing, and quality information, not consumer reviews.
Has Legend Oaks Healthcare and Rehabilitation Center G been fined?
As of August 1, 2026, the imported penalty records list $124,559 in reported fines for Legend Oaks Healthcare and Rehabilitation Center G. The individual penalty dates can differ from the Medicare file date; a listed fine does not establish that it was paid.
Does Legend Oaks Healthcare and Rehabilitation Center G have a Medicare abuse warning?
No. The current CMS Care Compare extract does not show an abuse warning icon for Legend Oaks Healthcare and Rehabilitation Center G in Gladewater, Texas.
How does Legend Oaks Healthcare and Rehabilitation Center G compare with other nursing homes in Texas?
Its overall CMS rating is 2 out of 5. A rating comparison is withheld because a matching source date or a usable rating is missing. Use the Texas report card and dated inspection history for context; inspection totals alone are not a like-for-like performance comparison.

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