CareSentinel

Federal Nursing-Home Survey Record

Legend Oaks Healthcare and Rehabilitation Center -

CCN 676048 · 1201 FM 2685, Gladewater, TX, 75647 · Operated within the THE ENSIGN GROUP chain

Does Legend Oaks Healthcare and Rehabilitation Center - have a federal violation or abuse history?

According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Legend Oaks Healthcare and Rehabilitation Center - (CCN 676048), in Gladewater, TX, has federal inspection findings on its record. In its current inspection cycle, CMS cited the facility for 8 deficiencies; the most serious carries scope/severity E on CMS's A–L scale. The most recent federal survey on file is dated 2025-02-12. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $124,559 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own. Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

The Federal Record

CMS has $124,559 in civil money penalties on file against this facility.

Below is this facility's federal survey record as on file with federal regulators (CMS). Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

Scope & Severity — current cycle

ANo Harm
BNo Harm
CNo Harm
DPotential
EPotential
FPotential
GActual Harm
HActual Harm
IActual Harm
JImm. Jeopardy
KImm. Jeopardy
LImm. Jeopardy

CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations, as on file with federal regulators (CMS).

Civil money penalties on file

$124,559

CMS has $124,559 in civil money penalties on file against this facility.

Overall CMS star rating: this facility vs the CMS-published state average

This facility: 2  ·  CMS state average: 2.7

Side-by-side with the CMS-published Overall CMS star rating for this state. This is the government's own published state average — not a CareSentinel-computed figure or delta.

Deficiency timeline — full federal history

2026-01-29
CURRENT CYCLE
F609S/S D

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

2026-01-21
CURRENT CYCLE
F689S/S D

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

2025-02-12
CURRENT CYCLE
F880S/S E

Provide and implement an infection prevention and control program.

2025-02-12
CURRENT CYCLE
F761S/S 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.

2025-02-12
CURRENT CYCLE
F558S/S E

Reasonably accommodate the needs and preferences of each resident.

2025-02-12
CURRENT CYCLE
F695S/S D

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

2025-02-12
CURRENT CYCLE
F807S/S D

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

2025-02-12
CURRENT CYCLE
F802S/S D

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

2024-10-23
HISTORICAL
F610S/S J

Respond appropriately to all alleged violations.

2024-10-23
HISTORICAL
F607S/S J

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

2024-10-23
HISTORICAL
F600S/S J

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

2024-10-23
HISTORICAL
F609S/S J

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

2024-06-19
HISTORICAL
F925S/S G

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

2024-06-19
HISTORICAL
F684S/S D

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

2024-02-22
HISTORICAL
F603S/S H

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

2024-02-22
HISTORICAL
F880S/S E

Provide and implement an infection prevention and control program.

2024-02-22
HISTORICAL
F563S/S D

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

2024-01-24
HISTORICAL
F695S/S E

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

2024-01-24
HISTORICAL
F761S/S 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.

2024-01-24
HISTORICAL
F757S/S E

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

2024-01-24
HISTORICAL
F641S/S E

Ensure each resident receives an accurate assessment.

2024-01-24
HISTORICAL
F558S/S D

Reasonably accommodate the needs and preferences of each resident.

2024-01-24
HISTORICAL
F689S/S D

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

2024-01-24
HISTORICAL
F607S/S D

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

2024-01-24
HISTORICAL
F758S/S 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.

2024-01-24
HISTORICAL
F657S/S D

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

2023-09-13
HISTORICAL
F689S/S J

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

2023-09-13
HISTORICAL
F600S/S D

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

2022-11-08
HISTORICAL
F697S/S J

Provide safe, appropriate pain management for a resident who requires such services.

2022-11-08
HISTORICAL
F686S/S J

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

2022-11-08
HISTORICAL
F842S/S D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

2022-11-08
HISTORICAL
F558S/S D

Reasonably accommodate the needs and preferences of each resident.

2022-11-08
HISTORICAL
F880S/S D

Provide and implement an infection prevention and control program.

2022-11-08
HISTORICAL
F742S/S D

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.

2022-11-08
HISTORICAL
F695S/S D

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

Each citation below is a federal survey finding, dated and labeled with its CMS deficiency tag, as on file with federal regulators (CMS). Older inspection cycles are de-emphasized; only the most recent cycle is current.

Document what happened

Were you or a loved one harmed at Legend Oaks Healthcare and Rehabilitation Center -?

Share a few details to put your inquiry on file. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. As qualified attorneys join our network in your area, one may reach out — we can’t guarantee contact yet, so we encourage you to consult a qualified attorney promptly on your own as well. There is no cost, and your information is handled with care.

Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

Step 1 of 3 · What happened

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Safety & abuse

Loss

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