Facility WatchInspection records for every certified US nursing home
Legend Oaks Healthcare and Rehabilitation Center -
1201 FM 2685 Gladewater, TX 75647 (903) 845-2175
CCN
676048
Certified beds
100
Ownership
Government - Hospital district
Chain
THE Ensign Group
Nurse staffing
3.63
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.46 hours per resident per day
Nursing staff turnover: 40% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected April 15, 2026
10 citations · Health
C
F0577No actual harm with potential for minimal harm · Widespread
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Deficient, Provider has date of correction · corrected April 16, 2026
C
F0732No actual harm with potential for minimal harm · Widespread
Post nurse staffing information every day.
Deficient, Provider has date of correction · corrected May 1, 2026
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected May 1, 2026
D
F0761No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected May 1, 2026
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected May 1, 2026
E
F0572No actual harm with potential for more than minimal harm · Pattern
Give residents a notice of rights, rules, services and charges.
Deficient, Provider has date of correction · corrected May 1, 2026 · under dispute by the facility
E
F0576No actual harm with potential for more than minimal harm · Pattern
Ensure residents have reasonable access to and privacy in their use of communication methods.
Deficient, Provider has date of correction · corrected May 1, 2026 · under dispute by the facility
E
F0585No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected May 1, 2026 · under dispute by the facility
E
F0679No actual harm with potential for more than minimal harm · Pattern
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected May 1, 2026
E
F0755No actual harm with potential for more than minimal harm · Pattern
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected April 24, 2026
Inspected January 29, 2026
1 citation · from a complaint investigation · Health
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected February 18, 2026
Inspected January 21, 2026
1 citation · from a complaint investigation · Health
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected February 4, 2026
Inspected February 12, 2025
6 citations · Health
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected March 14, 2025
D
F0802No actual harm with potential for more than minimal harm · Isolated
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Deficient, Provider has date of correction · corrected March 14, 2025
D
F0807No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Deficient, Provider has date of correction · corrected March 14, 2025
E
F0558No actual harm with potential for more than minimal harm · Pattern
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected March 14, 2025
E
F0761No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected March 14, 2025
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected March 14, 2025
Inspected October 23, 2024
4 citations · from a complaint investigation · Health
J
F0600Immediate jeopardy to resident health or safety · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Past Non-Compliance · corrected August 30, 2024
J
F0607Immediate jeopardy to resident health or safety · Isolated
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Past Non-Compliance · corrected August 30, 2024
J
F0609Immediate jeopardy to resident health or safety · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Past Non-Compliance · corrected August 30, 2024
J
F0610Immediate jeopardy to resident health or safety · Isolated
Respond appropriately to all alleged violations.
Past Non-Compliance · corrected August 30, 2024
Inspected June 19, 2024
2 citations · from a complaint investigation · Health
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected July 16, 2024
G
F0925Actual harm · Isolated
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Deficient, Provider has date of correction · corrected July 16, 2024
Inspected February 22, 2024
3 citations · from a complaint investigation · Health
D
F0563No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Deficient, Provider has date of correction · corrected March 21, 2024
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected March 21, 2024
H
F0603Actual harm · Pattern
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Deficient, Provider has date of correction · corrected March 21, 2024
Inspected January 24, 2024
9 citations · from a complaint investigation · Health
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected February 23, 2024
D
F0607No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Deficient, Provider has date of correction · corrected February 23, 2024
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected February 23, 2024
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected February 23, 2024
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected February 23, 2024
E
F0641No actual harm with potential for more than minimal harm · Pattern
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected February 23, 2024
E
F0695No actual harm with potential for more than minimal harm · Pattern
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected February 23, 2024
E
F0757No actual harm with potential for more than minimal harm · Pattern
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected February 23, 2024
E
F0761No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected February 23, 2024
Inspected September 13, 2023
2 citations · from a complaint investigation · Health
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected October 12, 2023
J
F0689Immediate jeopardy to resident health or safety · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected October 12, 2023
Penalties
Date
Type
Amount
October 23, 2024
Fine
$16,801
October 23, 2024
Fine
$16,801
October 23, 2024
Fine
$16,801
October 23, 2024
Fine
$16,801
June 19, 2024
Fine
$43,070
September 13, 2023
Fine
$14,285
Ownership transfers
Effective
Seller
Buyer
04/01/2017
Daffodil Healthcare, Inc.
Fannin County Hospital Authority
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.