Starfile / Texas

Legend Oaks Healthcare and Rehabilitation Center -

1201 FM 2685, Gladewater, TX 75647 · CCN 676048

Inspection history vs Texas & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$124,559

Number of fines

6

Number of penalties

6

Payment denials

0

Chain

Chain

THE ENSIGN GROUP

Facilities in chain

329

Chain avg overall

3.20 / 5

Inspection citations (35)7 immediate jeopardy2 actual harm

1. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2026-01-29 · Health

   Potential for more than minimal harm

2. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2026-01-21 · Health · corrected 2026-02-04

   Potential for more than minimal harm

3. EF0558Reasonably accommodate the needs and preferences of each resident.2025-02-12 · Health · corrected 2025-03-14

   Potential for more than minimal harm

4. DF0695Provide safe and appropriate respiratory care for a resident when needed.2025-02-12 · Health · corrected 2025-03-14

   Potential for more than minimal harm

5. EF0761Ensure 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 · Health · corrected 2025-03-14

   Potential for more than minimal harm

6. DF0802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.2025-02-12 · Health · corrected 2025-03-14

   Potential for more than minimal harm

7. DF0807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.2025-02-12 · Health · corrected 2025-03-14

   Potential for more than minimal harm

8. EF0880Provide and implement an infection prevention and control program.2025-02-12 · Health · corrected 2025-03-14

   Potential for more than minimal harm

9. JF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2024-10-23 · Health · corrected 2024-08-30

   Immediate jeopardy

10. JF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2024-10-23 · Health · corrected 2024-08-30

    Immediate jeopardy

11. JF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-10-23 · Health · corrected 2024-08-30

    Immediate jeopardy

12. JF0610Respond appropriately to all alleged violations.2024-10-23 · Health · corrected 2024-08-30

    Immediate jeopardy

13. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-06-19 · Health · corrected 2024-07-16

    Potential for more than minimal harm

14. GF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2024-06-19 · Health · corrected 2024-07-16

    Actual harm

15. DF0563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.2024-02-22 · Health · corrected 2024-03-21

    Potential for more than minimal harm

16. HF0603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).2024-02-22 · Health · corrected 2024-03-21

    Actual harm

17. EF0880Provide and implement an infection prevention and control program.2024-02-22 · Health · corrected 2024-03-21

    Potential for more than minimal harm

18. DF0558Reasonably accommodate the needs and preferences of each resident.2024-01-24 · Health · corrected 2024-02-23

    Potential for more than minimal harm

19. DF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2024-01-24 · Health · corrected 2024-02-23

    Potential for more than minimal harm

20. EF0641Ensure each resident receives an accurate assessment.2024-01-24 · Health · corrected 2024-02-23

    Potential for more than minimal harm

21. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-01-24 · Health · corrected 2024-02-23

    Potential for more than minimal harm

22. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-01-24 · Health · corrected 2024-02-23

    Potential for more than minimal harm

23. EF0695Provide safe and appropriate respiratory care for a resident when needed.2024-01-24 · Health · corrected 2024-02-23

    Potential for more than minimal harm

24. EF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2024-01-24 · Health · corrected 2024-02-23

    Potential for more than minimal harm

25. DF0758Implement 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 · Health · corrected 2024-02-23

    Potential for more than minimal harm

26. EF0761Ensure 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 · Health · corrected 2024-02-23

    Potential for more than minimal harm

27. DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2023-09-13 · Health · corrected 2023-10-12

    Potential for more than minimal harm

28. JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-09-13 · Health · corrected 2023-10-12

    Immediate jeopardy

29. DF0558Reasonably accommodate the needs and preferences of each resident.2022-11-08 · Health · corrected 2022-12-06

    Potential for more than minimal harm

30. JF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2022-11-08 · Health · corrected 2022-12-06

    Immediate jeopardy

31. DF0695Provide safe and appropriate respiratory care for a resident when needed.2022-11-08 · Health · corrected 2022-12-06

    Potential for more than minimal harm

32. JF0697Provide safe, appropriate pain management for a resident who requires such services.2022-11-08 · Health · corrected 2022-12-06

    Immediate jeopardy

33. DF0742Provide 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 · Health · corrected 2022-12-06

    Potential for more than minimal harm

34. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2022-11-08 · Health · corrected 2022-12-06

    Potential for more than minimal harm

35. DF0880Provide and implement an infection prevention and control program.2022-11-08 · Health · corrected 2022-12-06

    Potential for more than minimal harm

Ownership

Other facilities in Gladewater

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.