Legend Oaks Healthcare and Rehabilitation Center G
1201 Fm 2685, Gladewater, TX 75647 · Gregg County · 100 certified beds · avg 75 residents/day · certified since Dec 1, 2004
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Oct 23, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 30, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Oct 23, 2024 · F-0607 · triggered by a complaint
The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Why it matters: Without working prevention policies, mistreatment is more likely to happen and less likely to be caught.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 30, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Oct 23, 2024 · F-0609 · triggered by a complaint
The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Why it matters: When incidents aren't reported promptly, abusers may continue harming residents and outside authorities can't step in.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 30, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Oct 23, 2024 · F-0610 · triggered by a complaint
The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 30, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Sep 13, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 12, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 19, 2024 · F-0925 · triggered by a complaint
The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
Why it matters: Pests spread germs, contaminate food, and signal broader problems with cleanliness.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 16, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Feb 22, 2024 · F-0603 · triggered by a complaint
The facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment.
Why it matters: Forced isolation is emotionally harmful and can hide neglect or abuse from view.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Mar 21, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (39)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 23, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Apr 15, 2026 | E · Potential for harm, repeated | The facility did not give residents the required written notice of their rights, the facility's rules, the services offered, and what those services cost. |
| Apr 15, 2026 | E · Potential for harm, repeated | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Apr 15, 2026 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Apr 15, 2026 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Apr 15, 2026 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Apr 15, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 15, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 15, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 15, 2026 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Apr 15, 2026 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Jan 29, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jan 21, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 12, 2025 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Feb 12, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 12, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 12, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Feb 12, 2025 | D · Potential for harm, one-off | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Feb 12, 2025 | D · Potential for harm, one-off | The facility did not provide residents with enough to drink, or with drinks matching their needs and preferences, to keep them properly hydrated. |
| Oct 23, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 23, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Oct 23, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 23, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jun 19, 2024 | ▲ G · Actual harm, one-off | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Jun 19, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 22, 2024 | ▲ H · Actual harm, repeated | The facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to receive the visitors they choose, at the times they choose. · from a complaint |
| Jan 24, 2024 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jan 24, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 24, 2024 | E · Potential for harm, repeated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Jan 24, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Jan 24, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jan 24, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Jan 24, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jan 24, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 24, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Sep 13, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 13, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 2 | 1 | J ▲ |
| 2024 | 18 | 6 | J ▲ |
| 2025 | 6 | 0 | E |
| 2026 | 13 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
6 fines totaling $124,559.
| 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 |
| Sep 13, 2023 | Fine | $14,285 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.48 | 3.46 | 3.95 | top 37% in Texas; bottom 35% in the U.S. |
| Registered Nurse hours | 0.41 | 0.44 | 0.69 | top 44% in Texas; bottom 24% in the U.S. |
| Weekend total nurse staffing | 2.88 | 3.04 | 3.50 | bottom 47% in Texas; bottom 25% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.16 | 0.34 | 0.48 | bottom 10% in Texas; bottom 6% in the U.S. |
| Total nursing staff turnover (%) | 42.6 | 55.3 | 45.8 | top 27% in Texas; top 43% in the U.S. |
| RN turnover (%) | 40.0 | 54.6 | 42.9 | top 30% in Texas; top 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.11, RN 0.37, weekend 2.58. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Fannin County Hospital Authority | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/2017 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2017 |
| Daffodil Healthcare, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Daffodil Healthcare, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 09/29/2025 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2016 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Kegarise, Brandon | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2017 |
| Kegarise, Brandon | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Kegarise, Brandon | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2017 |
| National Health Investors, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2017 |
| Sanderson, Clark | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2017 |
| Shen, Hong-I | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/06/2021 |
| Shen, Hong-I | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/06/2021 |
| Shen, Hong-I | Individual | ADP of the SNF | NOT APPLICABLE | 05/06/2021 |
| Texas Nhi Investors, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How is pest control handled here, and when was the last treatment or inspection?"
- "Under what circumstances, if any, would a resident ever be kept in their room or separated from others?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Truman W Smith Children's Care Center | 1.0 mi | Gladewater, TX | ★★★★★ | 5/5 | |
| Pine Tree Lodge Nursing Center | 9.8 mi | Longview, TX | ★☆☆☆☆ | 1/5 | |
| Focused Care of Gilmer | 12.2 mi | Gilmer, TX | ★☆☆☆☆ | 1/5 | |
| Gilmer Nursing & Rehabilitation | 12.6 mi | Gilmer, TX | ★☆☆☆☆ | 1/5 | |
| Buckner Westminster Place | 13.2 mi | Longview, TX | ★★★★☆ | 3/5 | |
| Heritage at Longview Healthcare Center | 13.6 mi | Longview, TX | ★☆☆☆☆ | 2/5 | |
| The Oaks at Longview | 13.6 mi | Longview, TX | ★★★☆☆ | 4/5 | |
| Avir at Longview | 13.8 mi | Longview, TX | ★☆☆☆☆ | 1/5 | abuse |
| Longview Hill Nursing and Rehabilitation Center | 14.2 mi | Longview, TX | ★☆☆☆☆ | 1/5 | |
| Willow Rehab & Nursing | 14.3 mi | Kilgore, TX | ★★★☆☆ | 2/5 | |
| Arbor Grace Guest Care Center | 14.5 mi | Kilgore, TX | ★☆☆☆☆ | 2/5 | |
| Highland Pines Nursing Home | 14.6 mi | Longview, TX | ★☆☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 676048.