Government - Hospital district · 100 certified beds · CMS number 676048
Legend Oaks Healthcare and Rehabilitation Center G, Gladewater, TX
CMS records 39 health deficiencies at Legend Oaks Healthcare and Rehabilitation Center G in Gladewater, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Apr 15, 2026. The highest severity cited is J (immediate jeopardy to resident health or safety). 5 citations were at the immediate jeopardy level, 4 of them recorded as past non-compliance (fixed before the inspection). CMS lists 5 fines totaling $110,274 in the last three years.
- 39deficiencies, 3 cycles (TX median 25)
- 13in the latest cycle (TX median 8)
- Jhighest severity · Immediate jeopardy
- $110,274fines, last 3 years
- 2CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Legend Oaks Healthcare and Rehabilitation Center G as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Legend Oaks Healthcare and Rehabilitation Center G may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (13 deficiencies)
Standard inspection Apr 15, 2026. CMS counts 13 health deficiencies and 1 fire safety deficiency in this cycle.
May 23, 2026 · Complaint inspection
1 deficiency, highest D
F686 · Pressure ulcer prevention and care
Requirement cited (CMS): Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 26, 2026
Apr 15, 2026 · Standard inspection
10 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 1, 2026
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 1, 2026
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 24, 2026
F732 · Daily posting of nurse staffing
Requirement cited (CMS): Post nurse staffing information every day.
- Severity
- C No actual harm, potential for minimal harm, widespread
- Status
- Correction date May 1, 2026
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 1, 2026
F679 · Activities program
Requirement cited (CMS): Provide activities to meet all resident's needs.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 1, 2026
F585 · Grievances and how they are handled
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 1, 2026
F577 · Seeing inspection results
Requirement cited (CMS): Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
- Severity
- C No actual harm, potential for minimal harm, widespread
- Status
- Correction date Apr 16, 2026
F576 · Phone, mail, and internet access
Requirement cited (CMS): Ensure residents have reasonable access to and privacy in their use of communication methods.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 1, 2026
F572 · Notice of rights, rules, and services
Requirement cited (CMS): Give residents a notice of rights, rules, services and charges.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 1, 2026
Jan 29, 2026 · Complaint inspection
1 deficiency, highest D
F609 · Reporting suspected abuse and crimes
Requirement cited (CMS): Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 18, 2026
Jan 21, 2026 · Complaint inspection
1 deficiency, highest D
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 4, 2026
Previous cycle: 10 deficiencies (standard inspection Feb 12, 2025)
Standard inspection Feb 12, 2025. CMS counts 10 health deficiencies and 1 fire safety deficiency in this cycle.
Feb 12, 2025 · Standard inspection
6 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 14, 2025
F807 · Drinks and hydration
Requirement cited (CMS): Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 14, 2025
F802 · Enough kitchen and dining support staff
Requirement cited (CMS): Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 14, 2025
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 14, 2025
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 14, 2025
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 14, 2025
Oct 23, 2024 · Complaint inspection
4 deficiencies, highest J
F610 · Investigating and responding to allegations
Requirement cited (CMS): Respond appropriately to all alleged violations.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Past non-compliance (fixed before the inspection), Aug 30, 2024
F609 · Reporting suspected abuse and crimes
Requirement cited (CMS): Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Past non-compliance (fixed before the inspection), Aug 30, 2024
F607 · Abuse prevention policies
Requirement cited (CMS): Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Past non-compliance (fixed before the inspection), Aug 30, 2024
F600 · Freedom from abuse and neglect
Requirement cited (CMS): Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Past non-compliance (fixed before the inspection), Aug 30, 2024
Earlier cycle: 16 deficiencies (standard inspection Jan 24, 2024)
Standard inspection Jan 24, 2024. CMS counts 16 health deficiencies and 1 fire safety deficiency in this cycle.
Jun 19, 2024 · Complaint inspection
2 deficiencies, highest G
F925 · Pest control
Requirement cited (CMS): Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- Severity
- G Actual harm (not immediate jeopardy), isolated
- Status
- Correction date Jul 16, 2024
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 16, 2024
Feb 22, 2024 · Complaint inspection
3 deficiencies, highest H
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 21, 2024
F603 · Freedom from involuntary seclusion
Requirement cited (CMS): Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
- Severity
- H Actual harm (not immediate jeopardy), pattern
- Status
- Correction date Mar 21, 2024
F563 · Receiving visitors
Requirement cited (CMS): Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 21, 2024
Jan 24, 2024 · Standard + complaint inspection
9 deficiencies, highest E
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 23, 2024
F758 · Psychotropic drug safeguards
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 23, 2024
F757 · Avoiding unnecessary drugs
Requirement cited (CMS): Ensure each resident’s drug regimen must be free from unnecessary drugs.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 23, 2024
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 23, 2024
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 23, 2024
F657 · Care plan timing and team review
Requirement cited (CMS): Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 23, 2024
F641 · Accurate resident assessments
Requirement cited (CMS): Ensure each resident receives an accurate assessment.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 23, 2024
F607 · Abuse prevention policies
Requirement cited (CMS): Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 23, 2024
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 23, 2024
Sep 13, 2023 · Complaint inspection
2 deficiencies, highest J
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Oct 12, 2023
F600 · Freedom from abuse and neglect
Requirement cited (CMS): Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 12, 2023
Tags cited in more than one inspection
8 tags cited on more than one inspection date at Legend Oaks Healthcare and Rehabilitation Center G; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F689 Accident prevention and supervision | 3 | Jan 21, 2026; Jan 24, 2024; Sep 13, 2023 |
| F761 Drug labeling and secure storage | 3 | Apr 15, 2026; Feb 12, 2025; Jan 24, 2024 |
| F880 Infection prevention and control program | 3 | Apr 15, 2026; Feb 12, 2025; Feb 22, 2024 |
| F558 Accommodating individual needs and preferences | 2 | Feb 12, 2025; Jan 24, 2024 |
| F600 Freedom from abuse and neglect | 2 | Oct 23, 2024 (PNC); Sep 13, 2023 |
| F607 Abuse prevention policies | 2 | Oct 23, 2024 (PNC); Jan 24, 2024 |
| F609 Reporting suspected abuse and crimes | 2 | Jan 29, 2026; Oct 23, 2024 (PNC) |
| F695 Respiratory and oxygen care | 2 | Feb 12, 2025; Jan 24, 2024 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| Oct 23, 2024 | Fine | $16,801 |
| Oct 23, 2024 | Fine | $16,801 |
| Oct 23, 2024 | Fine | $16,801 |
| Oct 23, 2024 | Fine | $16,801 |
| Jun 19, 2024 | Fine | $43,070 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 3.11 h (below the Texas median of 3.27 h)
- RN hours per resident per day
- 0.37 h (about the same as the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 2.58 h
- Nursing staff turnover
- 42.6% (Texas median 52.1%)
- Administrators who left
- 1
- CMS overall rating
- 2 of 5
- Health inspection rating
- 2 of 5
- Staffing rating
- 2 of 5
- Quality measure rating
- 3 of 5
CMS figures for Legend Oaks Healthcare and Rehabilitation Center G, copied as published; Texas medians are ours.
Facility details
- Address
- 1201 Fm 2685, Gladewater, TX 75647
- Phone
- (903) 845-2175
- County
- Gregg
- Accepts
- Medicare and Medicaid
- Ownership
- Government - Hospital district
- Chain (CMS)
- The Ensign Group
- Certified beds
- 100
- Average residents per day
- 74.9
- In Medicare/Medicaid since
- Dec 1, 2004
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How does the home assess each resident's fall risk and plan to prevent falls? (F689, cited 3 times)
- How are medications stored and secured on each unit? (F761, cited 3 times)
- How do staff track and report infections among residents? (F880, cited 3 times)
- How does the home adapt rooms and routines for residents with limited mobility, vision, or hearing? (F558, cited 2 times)
Other nursing homes in Gladewater and the same chain
- Truman W Smith Children's Care Center
Gladewater · 13 deficiencies - The Eden of Las Colinas
Irving · 65 deficiencies - Northeast Rehabilitation and Healthcare Center
San Antonio · 57 deficiencies - Westpark Rehabilitation and Living
Euless · 54 deficiencies - Park Village Healthcare and Rehabilitation
DeSoto · 52 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.